Download PMTCT Refresher Course Objectives

Contraception for Clients with HIV
Curriculum
Participant Manual
The Contraception for Clients with HIV Curriculum and the
accompanying materials, including this Participant Manual, were
developed by Family Health International (FHI) in collaboration with
the ACQUIRE Project at EngenderHealth, as one of the resources for
Increasing Access to Contraception for Clients with HIV: A Toolkit.
The Toolkit is made possible by the generous support of the American
people through the United States Agency for International
Development (USAID) under the terms of the cooperative agreement,
Contraceptive and Reproductive Health Technologies Research and
Utilization (CRTU), No. GPO-A-00-05-00022-00 and, through the
ACQUIRE Project, under the terms of cooperative agreement, No.
GPO-A-00-03-00006-00. The contents are the responsibility of Family
Health International and do not necessarily reflect the views of USAID
or the United States Government.
© 2008 by Family Health International
Table of Contents
Session 1: Introduction ................................................................................................................. 1
Session 2: Overview of HIV, AIDS, and ARV Therapy ..................................................................... 6
Session 3: Why Integrate Family Planning and HIV Prevention, Care, and Treatment ...................... 15
Session 4: Provider Values and Attitudes and Client’s Rights (Stigma Reduction) ....................... 19
Session 5: Factors Affecting Contraceptive Method Choice and Overview of Medical
Eligibility Criteria ........................................................................................................ 26
Session 6: Contraceptive Method Options for Clients with HIV
Male and female condoms ........................................................................................ 29
Other barrier methods ............................................................................................... 30
Dual protection .......................................................................................................... 31
Session 7: Contraceptive Method Options for Clients with HIV
Hormonal contraceptive method options – Theoretical concerns .............................
Oral contraceptives ...................................................................................................
Progestin-only injectables .........................................................................................
Progestin-only implants and pills and emergency contraceptive pills (ECPs) ..........
38
43
49
56
Session 8: Contraceptive Method Options for Clients with HIV
Intrauterine devices (IUDs) ....................................................................................... 60
Session 9: Contraceptive Method Options for Clients with HIV
Male and female sterilization .................................................................................... 68
Fertility awareness-based (FAB) methods ................................................................ 71
Lactational amenorrhea method (LAM) and infant feeding options.......................... 73
Session 10: Integrating FP into HIV Services for Provision of Contraceptive Information,
Counseling, and Methods ................................................................................................... 77
FP/HIV service integration – client contact opportunities ........................................ 80
Sexual activity, pregnancy and contraception – raising the subject during counseling .. 82
Counseling clients with HIV about pregnancy ......................................................... 82
Counseling clients with HIV about contraception .................................................... 83
Additional counseling topics for clients with HIV ................................................... 84
Client-centered counseling framework ..................................................................... 85
What to say and do during the various stages of counseling ......................................... 86
Counseling observation checklist .............................................................................. 93
Session 11: Creating and Maintaining a Safe and Efficient Work Environment
Standard precautions in health care settings ............................................................. 94
Postexposure care and prophylaxis for injured health care staff ............................... 97
Recognizing and coping with stress in health care settings .................................... 100
Action plan .............................................................................................................. 101
Fact Sheets .............................................................................................................................................. 103
Medical Eligibility for Contraceptive Methods for Clients with HIV and AIDS: Summary Chart ............. 119
Participant Manual: Contraception for Clients with HIV Curriculum
Participant Manual: Contraception for Clients with HIV Curriculum
Contraception for Clients with HIV Curriculum
Participant Manual
SESSION 1: Introduction
This manual is part of a curriculum designed to orient health care providers to the
reproductive decisions and concerns of clients with human immunodeficiency virus (HIV).
It is believed that providers who adopt an integrated client-centered approach to addressing
the concerns of clients with HIV can better meet their clients’ needs. An integrated
approach to providing reproductive health (RH) services can create programmatic synergies
that may make services more attractive to clients with HIV and reduce the stigma often
associated with the disease. It may also afford more job satisfaction for providers who are
able to address the needs of their clients in a more holistic manner.
With the growing HIV epidemic, family planning (FP) can play a key role in preventing
further transmission of the virus. The training activities included in this course are designed
to help providers – nurses, midwives, and physicians – determine how best to incorporate
family planning into the integrated reproductive health services that they offer to all their
clients, especially those clients with HIV. How services are integrated depends what
resources are available, but integrated services can be offered in health centers, clinics,
hospitals, or home-based settings that offer primary care; palliative care; maternal and child
health; family planning; or HIV prevention, care, and treatment.
The course provides opportunities for providers to acquire knowledge and practice skills
specific to the family planning needs of clients with HIV. The activities are designed to
challenge providers to consider how these services can best be integrated into the settings
where they work. Providers who have never offered contraceptive methods may require
additional practice independent of this course to master the skills required for provision of
specific methods – this course does not include comprehensive objectives for skills
development in the provision of contraceptive methods. It is expected that providers, after
completing this course, will have the knowledge, skills, and attitudes required to adopt the
job responsibilities described below.
Capabilities upon Completion of Training
Upon completion of this training course, and with appropriate organizational support for their
performance, participants should be able to offer integrated FP and HIV services by performing
these essential tasks:

Counsel clients with HIV to enable them to make informed decisions about reproductive
health issues (e.g., assess individual risks, determine fertility intentions, make informed
decisions regarding contraception).


Provide contraceptive methods to clients with HIV or refer as appropriate.*
Maintain a safe, efficient, and welcoming integrated service environment, free from stigma
and discrimination, for clients and colleagues.
* The term “refer as appropriate” has been included to accommodate providers with various levels of
experience in providing family planning services. Realistic expectations that consider both the provider’s
capability and facility’s capacity to offer integrated services must be defined by the facility administrators
and the participant’s supervisors (preferably in consultation with the trainer) prior to initiation of training.
Participant Manual: Contraception for Clients with HIV Curriculum
page 1
Orientation to the Training
This manual is designed to be used as part of a comprehensive training program
where supervisors and administrators have defined and revised the job responsibilities
of the training participants, have documented their existing knowledge and skills, and
have established – in collaboration with the training facilitator – the specific
objectives of the training course. The training objectives must be designed specifically
to address the knowledge and skills deficits of the participants so that they will be
prepared to assume their new job responsibilities after the training. It is strongly
suggested that the training participants be involved in the preliminary planning for
service integration. At a minimum, participants should meet with their supervisors
prior to the training to ensure that the acquired knowledge and skills can be
immediately used and supported at the workplace.
Prior to the training, the provider should have a clear understanding of:

The specific services that will be offered at the facility

How the community members and clients will be informed about the expanded or
integrated services

What administrative policies, service delivery guidelines, and clinical procedures will
be adapted and how these changes will be communicated to all of the facility staff

Where, when, and by whom the new services will be offered – with a particular
emphasis on the specific services that the participant is expected to offer

Who will supervise the new services and service providers

How workers will acquire and maintain the knowledge and skills required to assume
the new responsibilities
During or immediately following the training, the provider should have an opportunity to
gain a clear understanding of:

How supplies and equipment will be acquired and maintained

When and where referrals will be made

How services will be reported, monitored, and evaluated
Training Materials
The curriculum includes the following materials:
Participant Manual. This manual includes materials needed to participate in the training
activities and reference information that can be used after the participants return to their
workplaces. It also includes an action plan that participants and their supervisors can use to
help facilitate the transfer of learning back to the workplace.
Facilitator Manual. This manual includes instructions and resource materials for
conducting the training activities.
Collateral materials to facilitate learning and provision of integrated services:
 Counseling Tool: Reproductive Health Choices for Clients with HIV to be used
when counseling clients with HIV and their partners to make informed reproductive
health decisions (also referred to as the “flip book”)
 Screening checklists to determine medical eligibility for combined oral contraceptives
(COCs), injectables (DMPA or NET-EN), intrauterine devices (IUDs), and
contraceptive implants
Participant Manual: Contraception for Clients with HIV Curriculum
page 2





Fact sheets about contraceptive methods and other HIV or AIDS related topics
(included at the back of the participant manual, can be used as job aids)
Client brochures on various topics that can be adapted to meet the needs of the
clients at a specific facility (e.g., materials on infant feeding)
Facility checklists to help providers and administrators determine what level of
integrated services are reasonable or evaluate the quality of the integrated services
they are offering
Supervisory tools for assessing the performance of supervisors at facilities where
integrated services are being provided
Full-text reference materials that can be shared with interested participants (e.g.,
Family Planning: A Global Handbook for Providers, CCP and WHO, 2008 update)
For a full list of the sources cited or used in this manual, see the references and resources
included in the appendices of the Facilitator’s Manual.
Course Objectives
The course objectives are organized into six content areas:
Overview of HIV, AIDS, and ARV Therapy
Participants will be able to:
 Define HIV and AIDS.
 Describe the progression of HIV disease.
 Describe the ways HIV is transmitted and how it may be prevented.
 Describe the scope of the HIV epidemic in their country or community.
 Explain how HIV affects women, especially the factors that make women more
vulnerable to HIV infection.
 Explain (in general terms) how ARV drugs work for treatment of AIDS, what is
included in highly active antiretroviral therapy (HAART) therapy, and how ARV
drugs can be used for prophylaxis.
Why Integrate Family Planning and HIV Prevention, Care, and Treatment
Participants will be able to:
 List the benefits of offering family planning to clients with HIV.
 Explain the potential benefits and challenges of integrating family planning and HIV
services.
Provider Values and Attitudes and Client’s Rights (Stigma Reduction)
Participants will be able to:
 Examine their personal values and attitudes toward people with HIV.
 Explain how personal values and attitudes may affect interactions with clients who
have HIV.
 Discuss the sexual and reproductive rights of clients with HIV.
 Discuss HIV-related stigma and discrimination as it applies to sexual and
reproductive rights.
 Describe how to identify and address stigma and discrimination when providing RH
services.
 Explore the range of reproductive health choices for clients with HIV and related
issues or concerns that may influence their decisions and fertility intentions.
 Describe how a provider can address the reproductive health concerns of clients with HIV.
Participant Manual: Contraception for Clients with HIV Curriculum
page 3
Contraceptive Methods and Family Planning for Clients with HIV
Participants will be able to:
 List method characteristics that affect contraceptive method choice.
 Explain the rationale for medical eligibility criteria and how they are applied.
 Provide an overview of available contraceptive methods, including effectiveness,
characteristics, mechanisms of action, benefits, side effects, eligibility criteria,
protection against sexually transmitted infections (STIs) including HIV, how to use,
when to return to the clinic, and common myths and misconceptions.
 List contraceptive methods available to women and couples with HIV.
 Describe how the presence of HIV, AIDS, and the use of or response to ARV
therapy affects method eligibility.
 Explain the concerns, theoretical or otherwise, related to the use of hormonal
contraception among women with HIV, including those who are taking ARV drugs.
 State the main counseling messages for women on ARV therapy who are planning to
use hormonal contraception.
 Explain the concerns related to the use of the lactational amenorrhea method
(LAM) by women with HIV, infant feeding options, and recommendations to
reduce mother-to-child transmission during breastfeeding.
Counseling and Client-Provider Interaction
Participants will be able to:
 Identify opportunities where family planning messages or services can be offered.
 Describe the process and content of counseling sessions tailored to services provided
to clients with HIV.
 Demonstrate the ability to counsel clients with HIV during role-plays while
addressing RH issues relevant to the clients described in the case studies.
Safe and Efficient Work Environment
Participants will be able to:
 Describe standard precautions applicable in clinical settings.
 Assess their individual occupational risk for HIV, including risk reduction strategies
that should be in place.
 Assess how integrating FP services affects standard precautions currently in place and
what measures may need to be added.
 Describe the management of occupational exposure to HIV.
Note: Since the risk of occupational exposure through provision of contraception is
minimal, this objective is recommended only for participants providing injectables,
IUDs, implants, tubal ligations, or vasectomies.
 Describe measures to minimize stress and enhance support for health workers in
integrated service settings.
 Develop a plan to facilitate the transfer of knowledge and skills from the training to
their workplace, with a focus on clarifying changes in job expectations with
supervisors and colleagues; clarifying procedures for record keeping, resupply, and
referral related to the new services; and creating mechanisms for practicing, using,
and maintaining new skills.
Optional objective: Participants will be able to track, refer, report, log, order, and maintain
supplies for new services using revised record-keeping form. Alternatively, interim recordkeeping tools, e.g., log or register book to track FP service activities, can be introduced.
Participant Manual: Contraception for Clients with HIV Curriculum
page 4
Course Schedule
Day 1 (~8 hours)
Day 2 (~8½ hours)
Day 3 (~8 hours)
Day 4 (~8 hours)
1.1 Welcome/Introductions
30 minutes
4.5 Identify/Address Stigma
30 minutes – Group Work/Discuss
10.3 Counseling Process/Content
60 minutes – Brainstorm/Group Work
1.2 Objectives/Structure/Rules
30 minutes
4.6 Stigma/Facility Evaluation
60 minutes – Evaluate/Discuss
7.3 FP Methods – Injectables
15 minutes – Small Group Present
45 minutes – Present/Discuss
1.3 Knowledge Pre-test
45 minutes
BREAK – 15 minutes
BREAK – 15 minutes
4.7 RH Choices for HIV+ Clients
30 minutes – Group Work/Present
2.1 HIV and AIDS Overview
45 minutes – Facts Game
5.1 FP Method Characteristics
10 minutes – Brainstorm
20 minutes – Present/Discuss
2.2 Scope of Epidemic
15 minutes – Presentation
5.2 FP Method Overview
30 minutes – Small Group Prep
2.3 Impact on Women
15 minutes – Brainstorm/Present
LUNCH – 60 minutes
2.4 ARV Therapy Intro
20 minutes – Small Group Present
LUNCH – 60 minutes
3.1 Benefits of FP
15 minutes – Discuss/Present
3.2 Integration Benefit/Challenges
15 minutes – Present/Discuss
4.1 Values/Attitudes to HIV
30 minutes – Reflect/Discuss
4.2 Values/Attitudes to HIV
30 minutes – Small Group
BREAK – 15 minutes
4.3 Attitudes/Opinions about HIV
60 minutes – Agree/Disagree
7.4 FP Methods – Other HCs
45 minutes – Present/Discuss
BREAK – 15 minutes
7.5 HIV/ARV Counseling Messages
5 minutes – Review Key Points
10 minutes – Brainstorm Messages
8.1 FP Methods – IUDs
15 minutes – Small Group Present
30 minutes – Present/Discuss
10.4 Counseling Sensitive Topics
60 minutes – Brainstorm/Discuss
BREAK – 15 minutes
Day 5 (~5 ¼+ hours)
11.3 HIV Risk Management
30 minutes –Discuss/Present
11.4 Minimize Stress
45 minutes – Brainstorm/Discuss
BREAK – 15 minutes
10.5 Counseling Practice
90 minutes –Practice Case Sessions
30 minutes –Group Discussion
11.5 Reporting
TBD – Demonstrate/Discuss
LUNCH – 60 minutes
11.6 Action Planning
60 minutes – Develop/Review
10.5 Counseling Practice (continued)
90 minutes –Practice Case Sessions
30 minutes –Group Discussion
LUNCH – 60 minutes
8.2 IUD Eligibility HIV+
15 minutes – Present/Discuss
BREAK – 15 minutes
12.1 Review/Ask
5 minutes – Write Question Cards
9.1 FP Methods – Sterilization/FAB
30 minutes – Present/Discuss
11.1 Standard Precautions
30 minutes – Define/Discuss
12.2 Knowledge Post-test
45 minutes
9.2 LAM/Infant Feeding Options
30 minutes – Present/Discuss
11.2 FP-related Occupational Risk
30 minutes –Discuss/Share
BREAK – 15 minutes
6.3 Condom Demonstration
15 minutes – Condom Race
20 minutes – Demo/Practice
9.3 FP Methods – Summary
15 minutes – MEC Matching Game
DAILY WRAP-UP
6.4 Condom Myths
25 minutes – Small Group/Discuss
LUNCH – 60 minutes
6.1 FP Methods – Condoms
15 minutes – Small Group Present
15 minutes – Present/Discuss
6.2 Dual Protection
5 minutes – Brainstorm/Present
10 minutes -- Present/Discuss
6.5 Negotiating Safer Sex
15 minutes – Brainstorm/Negotiate
BREAK – 15 minutes
7.1 HCs and HIV/ARV Concerns
30 minutes – Present
15 minutes – Fact/Theory Game
4.4 HIV+ Clients’ Rights/Stigma
30 minutes – Present/Discuss
7.2 FP Methods – COCs
15 minutes – Small Group Present
45 minutes – Present/Discuss
DAILY WRAP-UP
Assigned Reading – first half of flip
book
DAILY WRAP-UP
Assigned Reading – second half of
flip book
Participant Manual: Contraception for Clients with HIV Curriculum
10.1 Contact Points
60 minutes – Group Maps/Present
12.3 Review/Answer
15 minutes – Answer Question Cards
12.4 Course Evaluation/Closure
15 minutes – Evaluation
10 minutes – Wrap-up
CLOSE COURSE
BREAK – 15 minutes
10.2 Counseling Process/Content
60 minutes – Present/Discuss
DAILY WRAP-UP
Assigned Reading – counseling
section of Participant Manual
page 5
SESSION 2: Overview of HIV, AIDS, and ARV Therapy
Facts about HIV and AIDS
What is HIV?
HIV is the human immunodeficiency virus that causes AIDS. A member of a group of
viruses called retroviruses, HIV infects human cells and uses the energy and nutrients
provided by those cells to grow and reproduce.
What is AIDS?
AIDS is the acquired immunodeficiency syndrome, a disease in which the body’s immune
system breaks down and is unable to fight off certain infections, known as opportunistic
infections, and other illnesses that take advantage of a weakened immune system.
The virus enters the body and lives and multiplies primarily in the white blood cells, the
immune cells that normally protect us from disease. The hallmark of HIV infection is the
progressive loss of a specific type of immune cell called T-helper or CD4 cells. As the
virus grows, it damages or kills these and other cells, weakening the immune system.
AIDS is diagnosed in an HIV-positive person when the immune system is severely
damaged or when certain other serious infections or cancer occurs.
How quickly do people infected with HIV develop AIDS?
In some people, the T-cell decline and opportunistic infections that signal AIDS develop soon
after initial infection with HIV. Most people remain asymptomatic for 10 to 12 years, and a few
for much longer. As with most diseases, early medical care can help prolong a person’s life.
How HIV is transmitted?
 Through the exchange of bodily fluids (blood, semen, and vaginal secretions) during
sexual contact
 Through shared drug injection needles (infected blood can be exchanged between
people using the same needle and syringe)
 Through accidental sticks with needles that are contaminated with HIV infected blood
 Through the transfusion of infected blood or blood products
 From HIV-positive women to their babies during pregnancy, delivery, or
breastfeeding
Contrary to public perception, a person cannot become infected with HIV by drinking
from a water fountain, sitting on a toilet seat, hugging or touching a person with HIV, or
eating from plates and utensils. Saliva is not considered a transmission route for HIV.
Mosquitoes, fleas, and other insects do not transmit HIV.
Why are women more vulnerable to HIV infection?
Women’s vulnerability to HIV has several causes. First, women are more vulnerable to
HIV infection because of cultural and societal factors. These factors include gender
inequities that limit women’s opportunities, often making them economically dependent
on men. Inequitable relations between men and women also make it more difficult for
women to refuse unwanted sex or to negotiate safer sex.
Women may also be more susceptible to HIV infection for biological reasons. Their exposure
to HIV virus can be greater than men’s because they have a larger surface area, the vagina,
exposed to sexual fluids during intercourse. A complicating factor is a preference for “dry
sex” among some partners, which makes the vagina more susceptible to tears. In addition, a
common physiological condition known as cervical ectopy may increase the risk of
Participant Manual: Contraception for Clients with HIV Curriculum
page 6
chlamydia infection, which may facilitate the acquisition of HIV infection. Cervical ectopy
occurs when the regular (squamous) cervical epithelium on the outer surface of the cervix is
replaced by thinner, more fragile (columnar) epithelium from the cervical channel.
What are the signs and symptoms of HIV and AIDS?
Often people who are HIV-positive have few or no symptoms. Other times, symptoms of
HIV are confused with other illnesses, such as influenza. A few suffer a brief period
(three to 14 days) of fever, joint pain, rash, and swollen lymph nodes within a month of
being infected. Later, as the immune system grows weaker, a common group of warning
signs may appear, including fevers, night sweats, fatigue, weight loss, coughing, and
diarrhea. A frequent condition during this time is thrush, a type of yeast infection that
causes white spots or sores. Thrush may first show up in the mouth, but can also appear in
the vagina or rectum and on the skin.
Once the infection has reached the AIDS stage, certain opportunistic infections and cancers are
common. Among them are: Kaposi’s sarcoma, non-Hodgkin’s lymphoma, pneumocystis
pneumonia, cytomegalovirus, toxoplasmosis, mycobacterium avium complex, and tuberculosis.
Counseling about HIV prevention
Counselors should encourage and help their clients to:
 Speak openly with your partner about safer sexual techniques and HIV status.
 Get an HIV test to protect yourself and others (if HIV status is not known).
 Get tested with your partner as a way of saying that you care about each other and
intend to stay healthy.
 Use a latex condom with each vaginal, oral, or anal sexual encounter (or latex-free
condoms for those with latex allergies).
 Avoid sharing needles or syringes if you inject drugs; seek professional help to stop
using harmful or addictive drugs.
 If pregnant, get regular prenatal, intrapartum, and postpartum care, including
prevention of mother-to-child transmission (PMTCT) services if HIV-positive.
 If postpartum and infected with HIV, breastfeed exclusively for the first six months;
or if it is acceptable, feasible, affordable, sustainable, and safe, use replacement
feeding (e.g., formula, other milk substitutes) instead of breastfeeding.
HIV and AIDS treatment options
A person who has HIV or AIDS should try to stay healthy, which may require eating
nutritious foods, exercising, and getting enough rest. Treatment for HIV and AIDS includes:
 Antiretroviral therapy (ART). While not a cure, ART can slow the illness for many
years. The treatment consists of drugs taken every day for the rest of one’s life. A
short course of antiretroviral (ARV) drugs taken during pregnancy and/or delivery
reduces the risk of transmitting HIV from mother to child.
 Treatment of opportunistic infections. Such infections may occur when ARVs are not
available or when they are no longer effective as the person becomes resistant to them.
Adapted from:
American Foundation for AIDS Research (amfAR). Facts about HIV/AIDS.
New York: amfAR, 2001. Available: http://www.thebody.com/amfar/ounce.html
For additional information, see:
Family Health International (FHI). HIV/AIDS Care and Treatment: A Clinical Course for People
Caring for Persons Living with HIV/AIDS. Arlington, VA: Family Health International, 2004.
Available: http://www.fhi.org/en/HIVAIDS/pub/guide/careandtreatmentclinicalcourse.htm
Participant Manual: Contraception for Clients with HIV Curriculum
page 7
HIV and AIDS Fact Game
Category 1: General Information about HIV and AIDS
Question
Answer
What do HIV and AIDS stand for?
What is the “window period”?
Name at least four signs or symptoms that suggest a patient may have
AIDS.
Category 2: HIV Transmission
Question
Answer
List three main ways in which HIV infection is transmitted.
1.
2.
3.
What four body fluids may contain high concentrations of HIV?
What specific system of the body does HIV attack?
Participant Manual: Contraception for Clients with HIV Curriculum
page 8
Category 3: HIV Prevention
Question
Answer
What are the ABCs of prevention?
A.
B.
C.
Name at least four infection prevention techniques that protect both
health care providers and patients from HIV.
Why should an individual consider being tested for HIV? Name at least
two reasons.
Category 4: Infant Feeding
Question
Answer
Define exclusive breastfeeding.
What is the latest age that WHO recommends switching an infant from
breastfeeding to replacement feeding when the mother is an HIVpositive woman who elects to breastfeed?
What are the infant feeding options for women with HIV and what type
of feeding is not recommended for infants of HIV-positive women?
Participant Manual: Contraception for Clients with HIV Curriculum
page 9
Category 5: Mother-to-Child Transmission
Question
Answer
If 100 women with HIV gave birth to100 infants, how many of the
infants would typically become infected during pregnancy, delivery, and
breastfeeding without any intervention?
Name two maternal factors that increase the risk of HIV transmission
during pregnancy.
Name two factors that increase the risk of HIV transmission during
breastfeeding.
Participant Manual: Contraception for Clients with HIV Curriculum
page 10
ARV Therapy Basics
The introduction of antiretroviral drugs as part of HIV clinical care has transformed
HIV infection into a manageable chronic illness for many individuals with HIV.
ARVs are not a cure. They cannot completely eradicate HIV. But they can inhibit
replication of the virus, which effectively slows disease progression and improves a
patient’s quality of life.
ARVs:
improve
immune
function
decrease
viral load
Different ARV drugs attack HIV at different steps in the process of copying itself – first
when
Vs:it enters the cell and then when new copies want to leave the cell. To date, the
best results have been achieved by combining three drugs from two different classes of
antiretrovirals into a “cocktail.” The cocktail attacks at least two targets, thus increasing
the chance of stopping HIV replication and protecting new cells from infection.
This three-drug cocktail is called “highly active antiretroviral therapy,” or HAART.
HAART can dramatically reduce the level of virus in the blood. As a result of this
decrease in viral load, immune suppression is arrested, followed by improved immune
function, which results in fewer opportunistic infections and illnesses and an overall
improvement in the quality of life.
NRTI
NRTI
NNRTI
+
OR
=
Standard
HAART
Regimen
PI
The standard HAART regimen contains two nucleoside reverse transcriptase
inhibitors (NRTIs) and one non-nucleoside reverse transcriptase inhibitor (NNRTI) or
a protease inhibitor (PI). The World Health Organization (WHO) recommends several
regimens for HAART therapy using widely available ARV drugs. Other regimens,
using more than three ARV drugs, are currently being explored to counter drug
resistance that develops in some patients.
Because of their side effects and the possibility of drug resistance, ARV therapy is not
recommended for all patients with HIV. Several indicators are used to determine a
patient’s eligibility to receive ARV therapy. Clients with HIV should be evaluated by
a provider trained to determine the most appropriate course of action.
For additional information see:
World Health Organization (WHO). Antiretroviral Therapy for HIV Infection in Adults and
Adolescents: Recommendations for a Public Health Approach – 2006 Revision. Geneva: WHO, 2006.
Participant Manual: Contraception for Clients with HIV Curriculum
page 11
WHO HIV Clinical Staging and Criteria for Initiation of ARV Therapy
WHO Clinical
Stage 1:
Asymptomatic
WHO Clinical
Stage 2:
Mild Disease
WHO Clinical
Stage 3:
Advanced Disease
WHO Clinical
Stage 4:
Severe Disease
Weight
no weight loss
weight loss <10%
weight loss >10%
HIV wasting syndrome
Common
symptoms
include:
 no
 itching rash
 oral thrush
 esophageal thrush
 herpes zoster
 more than 1
 chronic herpes
 recurrent upper
month of
diarrhea
 persistent
unexplained
fever
 severe bacterial
infections (e.g.,
pneumonia)
 current
pulmonary
tuberculosis
simplex ulcerations
 lymphoma
 Kaposi’s sarcoma
 invasive cervical
cancer
 pneumocystic
pneumonia
 extrapulmonary
tuberculosis
 cryptococcal
meningitis
 HIV encephalopathy
 if CD4 not
 all in stage 4 are
symptoms
 or only
persistent,
generalized
lymphadenopathy
Criteria for
ARV
initiation:
 treat if CD4
<200
cells/mm3
respiratory
infections
 recurrent mouth
ulcers
 treat if CD4
<200 cells/mm3
available, treat
all in stage 3
 if CD4 available,
treat if <350
cells/mm3
medically eligible
ARV therapy is complex and should only be offered by trained providers.
For additional information see:
World Health Organization (WHO). WHO Case Definitions of HIV for Surveillance and Revised
Clinical Staging and Immunological Classification of HIV-related Disease in Adults and Children.
Geneva: WHO, 2007. Available: http://www.who.int/hiv/pub/guidelines/HIVstaging150307.pdf
Participant Manual: Contraception for Clients with HIV Curriculum
page 12
Classes of ARV Drugs
There are several common classes of ARV drugs currently available.
• NRTIs – Nucleoside Reverse Transcriptase Inhibitors
• NtRTIs – Nucleotide Reverse Transcriptase Inhibitors
• NNRTIs – Non-Nucleoside Reverse Transcriptase Inhibitors
• PIs – Protease Inhibitors
• Entry inhibitors and other new classes of drugs are also becoming available.
Classes
Nucleoside
Reverse
Transcriptase
Inhibitors
(NRTIs)
Common
Drugs
zidovudine
(ZDV or
AZT)
didanosine
(ddl)
stavudine
(d4T)
lamivudine
(3TC)
abacavir
(ABC)
emtricitabine
(FTC)
Nucleotide
Reverse
Transcriptase
Inhibitors
(NtRTIs)
tenofovir
disoproxil
fumarate
(TDF)
Non-Nucleoside
Reverse
Transcriptase
Inhibitors
(NNRTIs)
Protease
Inhibitors
(PIs)
Entry
Inhibitors
and Other New
Classes
nevirapine
(NVP)
efavirenz
(EFV, also
known as
EFZ)
delavirdine
(DLV)
indinavir
(IDV)
ritonavir
(RTV)
lopinavir
(LPV)
nelfinavir
(NFV)
saquinavir
(SQV)
atazanavir
(ATV)
amprenavir
(APV)
enfuvirtide
(T20, also
known as
Fuzeon®)
Note: ARVs are sometimes available as fixed dose combinations (FDC). In this case, each pill contains
a certain amount of two or three different drugs (e.g., Trizivir, an FDC of ZDV+3TC+ABC).
Use of ARV Drugs for HIV Prophylaxis
While HAART therapy is used for the treatment of patients with advanced HIV disease,
ARV drugs can also be used for the prophylaxis, or prevention, of HIV infection. ARV
drugs play a major role in the prevention of mother-to-child transmission (MTCT) of
HIV. Pregnant women with HIV who do not have indications for full-scale antiretroviral
treatment or do not have access to treatment should be offered ARV prophylaxis to
prevent transmitting HIV to their newborn. Currently, there are many different drug
regimens available, and their use depends on the availability of drugs, cost, in-country
resistance patterns, and possible side effects. Clinical trials have demonstrated that these
regimens can reduce the risk of MTCT by 34 percent to 50 percent. (Dabis, 2000)
ARV drugs can also be used for postexposure prophylaxis, or PEP, in cases of known
occupational exposure to HIV, such as a needle stick with infected blood, or when
exposure cannot be ruled out, as in the case of rape. PEP should be started as soon as
possible after the incident, ideally within hours. Dual or triple drug therapy is
administered because it is believed to be more effective than a single agent. A treatment
of four weeks is recommended. Other prophylactic uses of ARV drugs to prevent HIV
infection are currently under study. (U.S. Centers for Disease Control and Prevention, 2005)
Participant Manual: Contraception for Clients with HIV Curriculum
page 13
Why ARV Clients Benefit from Contraception
Women with HIV who receive ARV therapy receive the same contraceptive benefits
as all other women. Some additional benefits include:
•
Removing the potential for unintended pregnancy in an already complicated life
situation. Without concern about pregnancy, women can focus more on their ARV
regimens and other demands related to HIV infection.
•
Avoiding complicated pregnancy. Antiretrovirals can aggravate anemia and
insulin resistance that are common during pregnancy. When health is already
compromised, such effects could be severe.
•
Having access to a wider range of antiretroviral therapy when a woman is
protected from pregnancy. This is because some ARV drugs have harmful effects
on the fetus and should not be offered to women who may become pregnant while
on ARVs.
For example, the drug efavirenz, known as EFZ or EFV, is believed to be a potent
early teratogen – that is, an agent that may induce birth defects. WHO guidance states
that “EFZ should not be given to women of childbearing potential unless effective
contraception can be assured.” (WHO, 2004)
Participant Manual: Contraception for Clients with HIV Curriculum
page 14
SESSION 3: Why Integrate Family Planning and HIV
Prevention, Care, and Treatment
Family planning (FP) plays several roles in helping to maintain the health of individuals,
families, and communities. With the AIDS epidemic growing, family planning has
expanded its role by helping to prevent the spread of HIV. As shown in the diagram
below, comprehensive programs designed to prevent mother-to-child transmission
(PMTCT) of HIV, typically employ multiple strategies that focus on preventing the
acquisition and transmission of HIV and supporting the needs of a woman and her family.
Family planning and effective use of contraceptives play an important role in these
multipronged approaches by preventing unintended pregnancies among women with
HIV, thus decreasing the likelihood of HIV infection in children and helping to reduce the
chance that a child will become an orphan.
Prevention
of HIV in
women,
especially
young
women
Prevention
of
unintended
pregnancies
in HIVpositive
women
Prevention
of transmission
from an HIVpositive
woman to
her infant
Support for
mother and
family
Family
planning and
effective use of
contraceptives
Increasing access to family planning services for women with HIV can reduce births of
children who have a high probability of being infected with HIV and dying. (USAID, 2003)
Providing integrated reproductive health services that include family planning counseling
and access to contraception to women and couples with HIV can improve their lives and
those of their families.
• When FP services are accessible, clients with HIV experience the same health
benefits as others in their communities. Couples can limit the size of their families
to the number of children they desire and are able to care for. Women can space
their children effectively and reduce the risks associated with too many
pregnancies or pregnancies spaced too closely. Couples with HIV can also time a
pregnancy to take place when HIV transmission risk is lowest.
• Family planning can also reduce HIV infections among children by helping
women with HIV who do not want to have children avoid pregnancy.
• Women with HIV who are concerned that they may eventually die of AIDS may decide
to use contraception to avoid having children who may some day become orphans.
As we have seen, there are many benefits in providing family planning and effective
contraception. Unfortunately, there is also a large and growing unmet need for
contraception and other family planning services. Surveys estimate that more than
150 million married women of reproductive age worldwide have an unmet need for
contraception to postpone or avoid pregnancy. Unmet need for contraception creates a
particular hardship for women with HIV who may wish to avoid pregnancy but do not
have access to contraceptives or family planning services. (Population Reference Bureau and
Demographic and Health Surveys)
Participant Manual: Contraception for Clients with HIV Curriculum
page 15
One of the largest groups whose reproductive health (RH) needs are not being met is
young women. Evidence of unmet need in this group is seen in the high rates of
sexually transmitted infections (STIs), including HIV, unintended pregnancy, and
mortality and morbidity resulting from unsafe abortion.
Some of the causes of this unmet need include a lack of information and education
about sexuality, reproduction, and contraception, as well as limited skills for
establishing personal goals, developing strategies, and communicating expectations
with partners. Additionally, many young people do not have access to reproductive
health services that are prepared to meet the specific needs of adolescents.
Integrated Services Meet the Needs of Clients with HIV
The goal of integrated services is to provide holistic care that meets clients’ needs.
Depending on the structure of the health services, integration can be achieved in a
number of ways – including in vertical programs. For instance:
•
In an HIV and AIDS care facility, the goal of integration is to provide
comprehensive HIV prevention, counseling, testing, and treatment services in
which family planning is an integral component of care.
•
Similarly, in a family planning center, the goal of integration is to provide
comprehensive family planning services in which HIV prevention, counseling,
testing, and treatment is an integral component of care.
When feasible, some programs are adopting a comprehensive care approach to service
provision – thus collapsing their vertical programs and offering all reproductive and
primary care services in the same facility. The level of integration that any program
can achieve must be carefully considered to ensure that it is feasible and sustainable.
Why Integrate HIV and FP Services
Clients seeking HIV-related services and those seeking FP services share many
common needs and concerns which may make service integration appropriate in some
situations.
• Women seeking HIV-related services, such as PMTCT, counseling and testing, or
ARV treatment, are often sexually active and fertile.
•
A significant, though unknown, proportion of individuals seeking family planning
services are at risk for HIV infection or are already HIV-positive.
•
Some of these individuals know their HIV status, but many have not been tested.
•
Both groups need information about and access to contraceptives and possibly
information about how HIV affects their contraceptive options.
Therefore, it is important that HIV and AIDS programs provide family planning
information and services or referrals. It is equally important that family planning
programs take into consideration the needs of women with HIV and, at a minimum,
have strong links to HIV care and treatment programs and services.
Programmatic synergies can result from providing family planning and HIV services
together. An entry point that provides a range of services – such as family planning;
Participant Manual: Contraception for Clients with HIV Curriculum
page 16
maternal and child health services; and HIV testing, counseling, and treatment – may
be more attractive to clients. Clients may benefit when they can have multiple health
needs addressed in a single visit by providers who are able to take a more holistic
approach to client care. Combining services can also help overcome the stigma related
to HIV and AIDS, which is one of the major constraints to accessing HIV services.
In addition, offering more than one service creates richer contact opportunities for
clients and providers, giving providers more occasions to followup with clients,
provide information and counseling, and support drug and method adherence. It also
gives clients chances to ask questions, attend to all their reproductive health needs,
and become involved in their own health care.
Providing integrated services to clients with HIV requires that providers be crosstrained in a variety of issues. All providers need to know the different combinations of
antiretroviral drugs that may be used to treat HIV. They also need to know which
contraceptive methods are appropriate for women with HIV and AIDS and other
medical conditions that affect eligibility for specific methods.
It is not always feasible or practical to provide integrated services. In such cases, a
referral network should be in place and referrals to specialized services should be
offered.
Potential Benefits of Incorporating FP into Existing HIV Services
This section focuses on the benefits of incorporating FP into existing HIV services –
recognizing that there are comparable benefits to incorporating HIV services into
existing FP programs. Some potential benefits include:
• Access to contraceptive methods can be improved because the number and type of
delivery sites are increased. These sites may attract a different customer base –
people not normally reached through traditional FP clinics, such as young people
(single and married), men (including men who have sex with men and may also
have female partners), commercial sex workers, and injecting drug users. This
benefit is especially important in communities where the referral system is weak
and there are barriers to accessing family planning information and methods.
•
When a provider is assured that a client is using a reliable method of
contraception, he or she can prescribe ARV drugs that are contraindicated for
women who are or may become pregnant.
•
Providers may experience increased job satisfaction and improved morale when
their capacity to address the needs of their clients in a more holistic manner makes
clients more satisfied with the services that they receive. In addition, the new
skills that providers develop to meet the needs of clients may provide
opportunities for professional growth. However, these “opportunities” must be
carefully considered to ensure that providers do not become overwhelmed by
unrealistic expectations from clients or administrators.
Participant Manual: Contraception for Clients with HIV Curriculum
page 17
Benefits of Involving Men
Offering integrated services may also make them more appealing to men and male
partners. Individual providers and programs, whether integrated or not, should make
an effort to reach out to men with reproductive health messages and services.
Involving men in family planning and other reproductive health programs could have
several benefits. Male partner cooperation and participation can:
• Encourage male partners to seek HIV counseling and testing and support
disclosure of both partners’ HIV status.
• Help women to act on HIV prevention messages delivered through RH services.
• Help couples to make joint informed decisions about their fertility intentions and
reproductive health goals including STI/HIV prevention strategies.
• Improve client satisfaction and the adoption, continuation, and successful use of a
contraceptive method.
Although attracting men to RH services often presents a challenge, integrated services
offer a valuable opportunity to reach men and involve them in RH decisions in a more
meaningful way.
Practical Challenges to Integrating FP into Existing HIV Services
Just as there are potential benefits to integrating family planning into existing HIV
services there are also potential challenges. Integrating family planning services
increases the workload of providers in busy facilities. Provider “burn out” due to
unrealistic job expectations can become very costly for programs that fail to consider
the implications – especially in facilities that regularly experience staffing shortages and
high rates of staff turnover.
Integrating family planning services can also increase the intensity of HIV
consultations for both the provider and the client. It increases the amount of
information that the provider must share and expands the number of issues that a
client must consider and decide. As providers spend more time with each client, the
clients’ waiting time also increases.
Ensuring that a sufficient number of staff with appropriate knowledge and skills are
available to meet the increased demand for the integrated services presents another
challenge. To ensure high-quality family planning services, providers must develop
the skills necessary to offer family planning counseling, initiate contraceptive
methods, manage possible side effects, and understand when and where to refer
clients who require additional help.
Programs that integrate family planning must consider how existing services will be
re-structured to accommodate the new services – which providers will offer the
services, where and when they will be offered, and how community members and
existing clients will learn that the services are available. Program managers and
administrators must facilitate the integration of services by adapting the existing
record keeping, activity reporting, and logistics systems within the facility to ensure
that accurate client records are maintained; family planning commodities, supplies,
and storage facilities are available; and supportive supervision to providers is offered
on an ongoing basis.
Participant Manual: Contraception for Clients with HIV Curriculum
page 18
SESSION 4: Provider Values and Attitudes and
Client’s Rights (Stigma Reduction)
What if you had HIV or AIDS?
•
If you were told that you had HIV, in what ways would it change your life?
•
What do you think would be the most difficult part about being HIV positive?
•
Would you tell your sexual partner(s) that you have HIV? Why or why not?
•
If you had HIV, whom would you not tell? Why would you want to keep the
information from them?
•
What would you think about
having a(nother) child? Why?
•
What factors might make you
want to have a(nother) child?
•
If you were trying to decide
about having a(nother) child,
with whom would you discuss
this? Why? With whom
would you not discuss it?
Why?
Illustration: WHO, 2005.
•
If you had HIV, how would you want clinic staff to behave toward you?
•
How comfortable would you be talking to someone in your facility about having
sex, having another child, family planning or family planning methods? Why or
why not?
Participant Manual: Contraception for Clients with HIV Curriculum
page 19
Reproductive Health Rights of People with HIV
Because of the stigma and discrimination so often attached to HIV, it is particularly
important that health service providers be able to protect the reproductive rights of
women living with HIV. These rights include having access to sexual and
reproductive health services and sexuality education, being able to choose a partner,
deciding whether to be sexually active or not and deciding freely and responsibly the
number, spacing and timing of their children. Women also have the right to make
these decisions free of discrimination, coercion and violence.
– Sexual and Reproductive Health of Women Living with HIV/AIDS, WHO and UNFPA, 2006
The statement above concisely describes the reproductive rights of women with HIV
and highlights the important role that providers serve in protecting those rights and
ensuring that women with HIV are not subjected to stigma and discrimination.
Protecting RH Rights of Clients with HIV
Many people, including providers, incorrectly assume that individuals with HIV will not
be interested in or involved in sexual relationships. They may also believe that people
with HIV should not have children. As a result of these biases, women are often denied
the information and services that they need to prevent pregnancy, plan a safe pregnancy,
and prevent mother-to-child transmission of HIV. Provider biases combined with a
client’s fear of stigma and discrimination may limit access to family planning services
and antenatal and obstetric care.
In societies where couples are expected to produce children, HIV-positive individuals
who decide to have no children must contend with social disapproval from their families
and communities. In these situations, childlessness gives rise to suspicions of HIV
infection and results in an individual being ostracized. For these reasons, protecting the
reproductive rights of individuals with HIV is critical to ensuring that their basic human
rights are secured.
Clients’ Family Planning Rights
When providing health care services, providers should respect the rights of all their
clients, regardless of their HIV status. With regard to family planning, a client’s rights
include the right to decide whether to use family planning and which contraceptive
method to use.
To exercise that right, all individuals and couples should:
• Have access to information and services, free of any barriers. Barriers to access can
be geographic, economic, administrative, medical, psychosocial, or cognitive (that is,
not knowing where to obtain services).
• Have a variety of modern contraceptive methods from which to choose. Each
person’s method preference is influenced by a number of factors that need to be
considered during counseling.
• Be supported to make an informed, voluntary choice of contraceptive method.
• Receive the contraceptive method of their choice whenever possible. Research has
shown that a woman who receives her contraceptive choice is more likely to continue
using the method.
Women with HIV should be able to exercise their reproductive rights freely, whether they
choose to plan a pregnancy, space their children’s births, or limit childbearing.
Participant Manual: Contraception for Clients with HIV Curriculum
page 20
Factors Affecting Sexual and Reproductive Health Decisions
For individuals with HIV, there are many factors that can influence sexual and
reproductive health decisions – including decisions about whether or not to use
contraception. For a woman with HIV, these factors may include her own health, her
partner’s health, and her children’s health. It may also include whether she and her partner
have access to long-term ARV therapy.
Another important factor is whether a woman feels she can disclose her HIV status to her
partner or family without risking rejection, violence, or financial loss. Cultural myths and
misconceptions may also play a role in decision-making. For example, some women may
believe that they cannot get pregnant because of HIV infection.
Fear of disclosing their HIV status, and the stigma generally associated with condom use,
makes many clients reluctant to discuss condom use with their partners. Gender issues
often affect decisions about contraception and STI/HIV prevention. Partner opposition is
one of the most common reasons women cite for not beginning or continuing to use
contraception. It is important to involve men in decision-making whenever possible
because reproductive health decisions are more likely to be implemented when they are
made jointly by both partners. Clear information about contraceptive methods is essential
for women and couples to make an informed choice.
When providers are aware of the factors that can affect a client’s decisions and
understand the power of these influences, they are better equipped to ensure that clients
are making the best possible decisions.
Ensuring Informed Choice
Providers are the key to ensuring that clients’ rights are guaranteed. Effective counselors:
• Listen carefully to the client’s questions and concerns.
• Empathize with the client’s situation.
• Help clients make their own reproductive health decisions without letting personal
biases influence the information they present to clients.
Such providers give clients accurate information to enable them to choose the method that
best suits their needs and give information that allows clients to use their chosen method
safely and effectively. It is of utmost importance that clients be allowed to make their
own decisions. Clients are in the best position to decide what is right for them and their
particular situation. Providers are obligated to ensure that clients can make an informed
decision. Providers then must abide by that decision regardless of whether they personally
agree with it or not.
Participant Manual: Contraception for Clients with HIV Curriculum
page 21
Recognizing Stigmatizing Language and Discriminatory Actions
Instructions: Review the examples of stigmatizing and non-stigmatizing language and discriminatory
and non-discriminatory behaviors – add other examples from your own experience.
Stigmatizing Language
Non-stigmatizing Language
 AIDS victims or AIDS sufferers
experience opportunistic infections.
 Individuals living with HIV may
experience opportunistic infections.
 AIDS carriers can infect others with HIV.
 People living with HIV or AIDS can
transmit infection to others.
 HIV is transmitted from people with bad
blood.
 HIV is no longer a death sentence.
 Adolescents are in a high-risk group.
 You wouldn’t want your child to become
an AIDS orphan.
 People with HIV/AIDS …

 HIV can be transmitted by blood
containing the HIV virus.
 People can live positively with HIV.
 Some adolescents may engage in highrisk behaviors.
 Have you thought about what happens if
your child loses a parent?
 People who are HIV-positive …



Discriminatory Actions and Practices
in Health Care Setting
 Putting on gloves when taking a pulse,
blood pressure, or doing other
noninvasive tests on a patient with HIV
 Change of facial expression when
learning that a patient has HIV
 Denial of full, unconditional, high
quality care and treatment
 Isolating patients with HIV in a corner or
special ward, simply because they have
HIV (Note: It is good medical practice to
ensure that HIV patients are not placed near
another patient who has an infectious
disease, such as TB or diarrhea, to protect
the patient with HIV from contracting that
infection.)
 Refusing to touch a patient with HIV
 Expressing a fatal prognosis – there are
“no options” or “there is nothing that we
can do”
 Treating HIV differently from other
chronic medical conditions when coding
or labeling charts and patient records
Non-discriminatory Actions and
Practices in Health Care Setting
 Not wearing gloves during noninvasive
exams or when giving pills
 Warm greetings that show care and
compassion
 Ensuing that each client’s right to
respect, privacy, dignity, and holding an
opinion are upheld
 Positive nonverbal communication
(nodding, smiling eye contact, touching)
 Emotional support
 Listening
 Ensuring confidentiality




Source: Reducing Stigma and Discrimination Related to HIV and AIDS, Participant’s Handbook, EngenderHealth, 2004.
Participant Manual: Contraception for Clients with HIV Curriculum
page 22
Facility Checklist: Client’s Rights and Prevention of Stigma and Discrimination
Instructions: Use the items on the facility checklist to evaluate how well your facility meets
the standards for ensuring clients rights and preventing stigma and discrimination.
Client’s Rights
1. Clients are provided with
accurate, appropriate,
understandable information
related to their health care.
2. Providers use educational
materials to support
information sharing.
3. Services are affordable and
convenient to clients, without
physical and social barriers.
4. Providers support informed
choice by providing accurate,
complete, and understandable
information with options that
promote well-considered
decision-making.
5. Providers are skilled and
practice in accordance with
service delivery guidelines.
6. Staff maintains client privacy
and confidentiality at all times.
7. All clients are treated with
respect and consideration,
ensuring comfort during
procedures.
8. Continuity of services and
supplies are ensured; follow-up
and referral are the norm.
Achieved
Prevention of Stigma and
Discrimination
Achieved
9. Clients are welcome to services
regardless of age, class, color,
ethnicity, sexual orientation,
sexual or drug use behavior,
marital status, or HIV status.
10. All clients are treated competently,
equally, fairly, and respectfully,
regardless of age, class, ethnicity,
sexual orientation, sexual or drug
use behavior, marital status, or
HIV status.
11. Services are provided to clients
known to be HIV-positive
without separating them from the
general client population.
12. Prior to invasive procedures,
patients are not selectively tested
for HIV without their consent.
13. Health care staff do not wear
gloves or masks inappropriately
with people who are HIV-positive
or presumed to be (only use
gloves and masks as indicated by
standard precautions).
14. Providers help clients to develop
a personal strategy to improve
their health regardless of their
HIV status.
15. The facility avoids posting labels
or signs that would draw
attention to clients with HIV.
16. Staff avoids nonverbal
communication that portrays
disgust, scorn, or disrespect
(facial expression or hand
gestures) when interacting with
clients known or thought to be
HIV-positive or when handling
their utensils or clothing.
17. HIV awareness and sensitization
training are provided to all staff
(as needed).
Source: Reducing Stigma and Discrimination Related to HIV and AIDS, Participant’s Handbook, EngenderHealth, 2004.
Participant Manual: Contraception for Clients with HIV Curriculum
page 23
Reproductive Choices and Decisions for Clients with HIV
Women with HIV and their partners often need to make a variety of reproductive
health decisions about pregnancy, childbearing, and contraceptive practice. They
should be free to make these reproductive choices for themselves, just as other women
and couples do. However, being HIV-positive may make women more vulnerable to
societal, religious, or family pressures than women without HIV. Counselors must
take special care to ensure that women with HIV do not feel coerced or pressured into
making certain reproductive choices.
Pregnancy in Women with HIV
Based on current research findings, it appears that pregnancy in women with HIV does
not accelerate progression of the disease. However, pregnancy often carries serious
consequences for the infants. Without treatment, about one-third of HIV-positive mothers
pass the virus to their newborns during pregnancy, delivery, and breastfeeding. Some
evidence suggests that pregnancy in women with HIV increases the risk of stillbirths and
infants with low birth weight. Nonetheless, for many couples with HIV who choose to
conceive, the perceived benefits of having a child outweigh the increased risk of adverse
pregnancy outcome.
Three positive developments – the impact of ARV therapy on the health and longevity of
many people with HIV; the increasing availability of effective means for reducing motherto-child HIV transmission; and wider availability of support and care services for families
dealing with HIV – may encourage women with HIV to reconsider decisions about sex,
relationships, and childbearing.
The reasons why many women with HIV consider pregnancy include:
• An intense desire to bear children.
• Societal, familial, and other relationship pressures to have children.
• Fear that the children they already have may die.
People who are unable
• Concern about reduced fertility related to HIV infection.
to have children find it
• Reassurance that PMTCT programs reduce the risk of
difficult to lead happy
having an HIV-positive child.
lives.
– Man on ART
• Expectations of receiving ARV therapy and living long
enough to see their children grow up.
• Concern that avoidance of pregnancy might generate suspicion about one’s HIV status.
• Fear that the potential consequences of disclosing one’s HIV-positive status to a
partner might include violence, abandonment, and loss of finances for children.
Avoiding Childbearing among Clients with HIV
Alternatively, many sexually active women and couples with HIV might not want to bear
children and therefore desire contraception. Their reasons to avoid or postpone pregnancy
are often the same as those of women who are not HIV-positive: maintaining family
economic status, achieving desired family size, and healthy spacing and timing of the
births of their children – at least 24 months apart.
A woman with HIV may also want to avoid childbearing for other reasons, such as:
• Concern that pregnancy will further compromise her
health, especially if it is already compromised by AIDS- The community questions a
woman falling pregnant
related symptoms. Her partner or spouse may be HIVwhile she knew her HIV
positive or have symptoms. In the absence of ARV
status.
– Woman with HIV
therapy and treatment for opportunistic infections, the
length and quality of life may be severely compromised.
Participant Manual: Contraception for Clients with HIV Curriculum
page 24
•
•
•
Fear of transmitting HIV to children she might conceive.
Fear of leaving orphans, because HIV infection is likely to shorten her life,
particularly without treatment. Parents are naturally concerned about who will care
for their children if they are no longer able to do so.
Fear that others will be unwilling to care for the family during illness, due to AIDSrelated stigma and discrimination.
Access to Information and Services is Key
In both resource-poor and resource-rich countries, women who learned that they have HIV
reported lower desired fertility levels than did women in the general population. However,
HIV-positive women’s knowledge of contraception and their access to family planning
services can be limited. Such services help women with HIV consider their reproductive
choices, plan for the future, avoid unintended pregnancy, time pregnancy when health is
optimal, and reduce HIV transmission to their children. Contraceptive counseling sessions
also offer opportunities for prevention counseling to reduce the chances that women will
transmit HIV to their partners. When provided access, women with HIV will use family
planning. (King, 1995)
Providers should help clients with HIV realize their reproductive health goals by
structuring services that are customized to fulfill their needs, including either pregnancy
counseling and services or accurate, unbiased counseling about contraception and access
to the client’s method of choice. In addition, all clients should receive counseling and
information about HIV and AIDS and possible treatment options.
1. Fertility decision:
desire pregnancy?
Pregnancy
desired
Yes
No
2. Informed decision(s):
contraceptive method?
STI/HIV prevention?
Contraceptive
counseling
Ongoing HIV
counseling
Intended
pregnancy
Safe/effective
contraception
3. Treatment decision(s):
ARV therapy for self
and partner?
PMTCT?
Pregnancy
counseling
ARV
treatment
Yes
PMTCT
services
No
Yes
No
As illustrated above, depending on the circumstances, the decisions a provider should
guide a client through may include:
• A decision about fertility: Is pregnancy desired at this point in time or not?
• If pregnancy is not desired, there are reproductive health decisions, such as which
contraceptive method to choose and what to do about STI/HIV prevention.
• If pregnancy is desired, there are decisions about how to achieve pregnancy safely
with minimal risk of transmission. If pregnant, there are decisions about PMTCT and
considerations related to breastfeeding and the risk of HIV transmission.
• If ARV therapy is available: Is it indicated and desired? (Adapted from: Cates, 2001)
Participant Manual: Contraception for Clients with HIV Curriculum
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SESSION 5: Factors Affecting Contraceptive Method
Choice and Overview of Medical
Eligibility Criteria
An individual’s decisions about contraception are shaped by many factors. It is
important for providers to understand these factors so that they can help women and
couples with HIV make informed decisions about which contraceptive method to use.
Factors Affecting Method Choice
Factors that women and couples with HIV may consider when they decide which
contraceptive method to use include:
• How safe and effective the method will be.
• Whether the method meets a desire for short-term, long-term, or permanent
protection.
• Possible side effects of the method.
• How easy it will be to use.
• Whether the method is affordable and access to resupply is easy.
• How it may interact with other medications, including ARVs.
• Whether it provides protection from STI/HIV transmission and acquisition.
• Whether partner involvement or negotiation are required.
If a woman is postpartum, the effect that the method may have on breastfeeding could
also play a role.
Pregnancy Rates by Method
Spermicides
Female condom
Standard Days Method
Male condom
Oral contraceptives
DMPA
IUD (TCu-380A)
Rate during perfect use
Female sterilization
Rate during typical use
Implants
0
30
10
20
25
5
15
Percentage of women pregnant in first year of use
For women who want to avoid childbearing, contraceptive method effectiveness (how
well a method works) is one of the most important characteristics for choosing a method.
As depicted in this chart, contraceptive failure can occur with any method; however,
some methods are more effective than others. This graph shows pregnancy rates for
various contraceptive methods. The black rectangles show pregnancy rates for perfect
use, reflecting how often a contraceptive method fails when it is used both correctly and
Participant Manual: Contraception for Clients with HIV Curriculum
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consistently. The gray rectangles show pregnancy rates for typical use, reflecting how
often a contraceptive method fails in real-life situations, when it may not always be used
correctly and consistently. Typical use rates vary depending on user characteristics, user
behavior, the adequacy of counseling, and access to resupply. (Global Handbook, 2007)
Differences between correct and typical use rates are greater for some methods than
for others. Client-controlled methods may have low pregnancy rates with correct and
consistent use but higher pregnancy rates with typical use. For example, combined
oral contraceptives have a pregnancy rate of 0.3 percent when used correctly and
consistently but a pregnancy rate of 8 percent with typical use. In contrast, the
pregnancy rates for typical use of intrauterine devices (IUDs) or injectable
contraceptives are almost the same as those for their correct and consistent use
because the effectiveness of these methods depends little on user behavior. For
example, the TCu-380A IUD has a pregnancy rate of 0.6 percent with correct and
consistent use and a rate of 0.8 percent in typical use. When considering the
pregnancy rates for various methods, keep in mind that women who use no method at
all have a risk of pregnancy as high as 85 percent over one year.
Medical Eligibility for Contraceptives
The characteristics of contraceptive methods and how these fit with an individual’s
lifestyle influence a client’s decisions about method choice. Another consideration is
whether the client has any medical conditions that would make the use of a particular
method unsafe. Several years ago, WHO assembled a team of experts to review the
available evidence and organize the findings in a manner that could be readily used by
providers to determine a client’s medical eligibility for a particular method. The
recommendations of the expert review team are summarized in the document Medical
Eligibility Criteria for Contraceptive Use. The team of experts meets periodically to
review new research findings and update their recommendations. The most recent
version, the third edition, was published in 2004. Additional changes to the MEC
were introduced in April of 2008. These changes are reflected in the technical
information included in this manual. (WHO, 2004; updated 2008)
The document provides guidance on the safety of 19 contraceptive methods for
women and men with specific characteristics or known medical conditions. These
characteristics and conditions range from age, smoking, and parity to cardiovascular
disease, cancer, and infections. Of particular interest to users of this curriculum are
the recommendations related to infection with HIV, the presence of AIDS, and the use
of ARV therapy.
WHO Eligibility Criteria
Category
Description
When clinical judgment is available
1
No restriction for
use
Use the method under any circumstances
2
Benefits generally
outweigh risks
Generally use the method
3
Risks generally
outweigh benefits
Use of method not usually recommended,
unless other methods are not
available/acceptable
4
Unacceptable
health risk
Method not to be used
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For each contraceptive method, medical conditions are classified into categories based
on the risks and benefits associated with use of the method among women with those
conditions.
The WHO Medical Eligibility Criteria (MEC) uses four categories to classify medical
conditions:
•
Category 1: For women with these conditions, the method presents no risk and can
be used without restrictions.
•
Category 2: For women with these conditions, the benefits of using the method
generally outweigh the theoretical or proven risks. Women with category 2
conditions generally can use the method, but follow-up by the provider may be
appropriate in some cases.
•
Category 3: For women with these conditions, the theoretical or proven risks of
using the method generally outweigh the benefits. Women with category 3
conditions generally should not use the method. However, if no better options for
contraception are available or acceptable, the provider may judge that the method
is appropriate, depending on the severity of the condition. In such cases, ongoing
access to clinical services and careful follow-up by the provider are required.
•
Category 4: For women with these conditions, the method presents an
unacceptable health risk and should not be used.
In some cases, a particular condition is assigned to one category for initiation and
another for continuation of the method. In other words, the category may depend on
whether a woman with the condition wishes to initiate the contraceptive method or
was already using that method when she developed the condition.
In situations where clinical judgment is limited, such as community-based distribution
programs, the four-category classification framework can be simplified into two
categories. When simplified for these situations, categories 1 and 2 indicate that the
method can be used, while categories 3 and 4 indicate that the woman is not medically
eligible to use the method.
The Quick Reference Chart for the WHO Medical Eligibility Criteria for
Contraceptive Use can be found with course materials. It provides an easy reference
to some of the more common conditions or characteristics that may affect a client’s
medical eligibility for three methods, COCs, DMPA, and IUDs.
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SESSION 6: Contraceptive Method Options for Clients
with HIV
Contraceptive options for women with HIV are similar to those of women without
HIV and include:
• barrier methods
• oral contraceptive pills
• injectables
Couples with HIV
have a wide range
• implants
of methods from
• intrauterine device (IUD)
which to choose.
• female and male sterilization
• lactational amenorrhea method (LAM)
• fertility awareness-based methods
Male and Female Condoms
The condom is the only method that has the ability to prevent transmission of
STIs/HIV and prevent pregnancy. However, the effectiveness for both pregnancy and
STI/HIV prevention depends greatly on the client’s ability to use condoms
consistently and correctly. In real-life situations, correct and consistent use may be
difficult to achieve. Condoms may not be used with every act of intercourse or are
sometimes used incorrectly. When used correctly every time a couple has intercourse,
the male condom has a pregnancy rate as low as 2 percent, and the female condom
has a rate of 5 percent. In common use, their pregnancy rates are much higher –
around 15 percent for the male condom and 21 percent for female condom. (Hatcher,
2007)
Pregnancy rates:
Male Condom
Female Condom
Perfect use
2%
5%
Typical use
15%
21%
Condoms Prevent HIV/STI Transmission
Condoms are the only method proven to reduce the risk of all STIs, including HIV.
One recent review of multiple studies found that typical condom use results in an
80 percent reduction in HIV incidence, a level of protection slightly less effective
than for pregnancy. (Weller, 2002)
The most conclusive evidence of condom effectiveness in reducing HIV transmission has
come from studies of serodiscordant couples, in which one person is HIV-positive and the
other person is not. One study demonstrated that with consistent condom use, the HIV
infection rate among the uninfected partners was less than 1 percent per year. However, in
situations where one partner is definitely HIV-positive, inconsistent condom use was
shown to be as risky as not using condoms at all – 13.3 percent of inconsistent users
became infected compared to 14.4 percent of non-users. (Deschamps, 1996)
Condoms are most effective in preventing STIs that are transmitted through bodily
fluids, such as HIV, gonorrhoea, and chlamydia. They are less effective against STIs
that are transmitted through skin-to-skin contact, such as genital herpes and warts,
because the condom may not cover the entire affected area.
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Condom Use by Clients with HIV
The WHO Medical Eligibility Criteria classify the conditions HIV-infected, the
presence of AIDS, and use of ARV therapy as category 1 for condom use, meaning
that condoms can be used without restrictions.
WHO Eligibility Criteria
Condition
Category
HIV-infected
1
AIDS
1
ARV therapy
1
Male and female condoms are the only methods that prevent HIV and STI
transmission between partners. They can also prevent transmission of a different HIV
strain to a person who is already HIV-positive, known as superinfection. As typically
used, condoms are less effective for pregnancy prevention than some other methods,
while other methods provide no protection from STIs/HIV. For these reasons,
counseling of clients or couples should focus on strengthening their ability to
consistently and correctly use condoms, either alone or in combination with another
method, to prevent both STI/HIV and pregnancy.
Other Barrier Methods
Unlike condoms, other barrier methods are not suitable options for clients with HIV.
Spermicides alone offer only limited protection from pregnancy. Failure rates for
spermicides vary from 18 percent when used consistently and correctly to 29 percent
with typical use. In typical use, spermicides are not used on some occasions or are
used incorrectly. (Hatcher, 2007)
Spermicides containing nonoxynol-9 do not protect against HIV infection or other
STIs. Spermicides may even increase the risk of HIV infection in women using these
products frequently. This may be because nonoxynol-9 can disrupt the epithelium, or
lining, of the vagina, thereby facilitating invasion by an infective organism. Advise
women who have multiple daily acts of intercourse to choose another method of
contraception. (Wilkinson, 2002; WHO, 2002; Van Damme 2002)
In typical use, diaphragms are associated with relatively high rates of pregnancy.
When diaphragms are used with spermicides, as recommended, about 6 percent of
users experience an unintended pregnancy during the first year with correct and
consistent use, while the failure rate for typical use is about 16 percent. (Hatcher, 2007)
It is possible that diaphragms offer limited protection from STIs, including HIV. This
is because a diaphragm blocks entrance to the cervix, and gonorrhoea and chlamydial
infection are acquired in the cervix but not the vagina. The cervix is also an entry
point for many HIV infections because the endocervical lining is thinner and more
fragile than the lining of the vagina, and therefore more vulnerable to infection.
Studies are under way to determine whether the diaphragm reduces the risk of
transmission of HIV or other STIs. (Moench, 2001; Hu, 2000; Padian, 2007)
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Spermicide and Diaphragm Use by Clients with HIV – Not Recommended
The WHO Medical Eligibility Criteria does not recommend the use of spermicides and
diaphragms with spermicides for women with HIV or AIDS. Women with HIV or AIDS,
including those who receive ARV treatment, should generally not use spermicides because
they may be at increased risk of infection with another strain of HIV, also known as superinfection. Documented instances of superinfection, while rare, have been associated with
faster disease progression and failure of antiretroviral therapy. (WHO, 2004; updated 2008;
Gottlieb, 2004)
If a woman with HIV desires reliable pregnancy protection, she should be encouraged
to consider other, more effective methods of contraception. Because spermicides
provide no protection against transmitting STIs/HIV, and it is not clear whether and to
what extent the diaphragm provides protection, condom use should be encouraged to
prevent infection transmission between partners.
Dual Protection
What is dual protection?
Dual protection is a strategy that protects clients from both unintended pregnancy and
STI/HIV infection/re-infection at the same time.
How can clients protect themselves from both unintended pregnancy and STI/HIV
infection at the same time?
Clients can do that by:
 Using condoms alone (male or female) consistently and correctly; with emergency
contraception for pregnancy prevention should a condom accident occur.
 Using male or female condoms plus another contraceptive method for added
protection against pregnancy (dual method use – see below).
 Maintaining a closed sexual relationship between uninfected partners combined
with a contraceptive method.*
 Engaging in other satisfying but safe forms of intimacy (actions that avoid contact
with a partner’s semen or vaginal secretions).
 Avoiding unprotected penetrative sex (abstinence) and delaying sexual debut.
How does dual protection counseling relate to the concept of “informed choice”?
Dual protection counseling upholds the concept of informed choice by making sure
that clients are aware of their risks for both unintended pregnancy and STI/HIV
infection or reinfection while making family planning decisions.
Clients are not making truly informed choices about family planning unless they are
aware of their risks for STI/HIV infection or reinfection and know how effective the
various family planning methods are in preventing STIs/HIV and pregnancy. Dual
protection counseling ensures that clients are aware, knowledgeable, and informed.
What are some strategies for promoting dual protection effectively?
 Provide complete, accurate, unbiased information about the effectiveness of
condoms in preventing both pregnancy and STI/HIV infection or reinfection.
*
A closed sexual relationship is one in which partners stay faithful to each other and have no other
sexual partners.
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



During counseling, help women to consider the effects of their decisions – both
positive and negative, and recognize the limitations that many women have in
negotiating condom use (e.g., insisting on condom use may lead to violence or
abandonment).
During counseling, build clients’ skills and confidence (using demonstration and
practice) regarding how to use condoms, communicate with their partners, and
negotiate condom use.
During counseling, suggest ways for making condoms sexy and fun to use.
Involve men in counseling and education. Conduct ‘couples counseling’ when
feasible.
Counseling about Dual Method Use
Providers can help clients understand the benefits of dual method use by considering:
 the limitations of a single-method approach;
 their individual risk of pregnancy and the implications of an unintended
pregnancy;
 whether their partners have HIV or another STI; and
 the negative consequences of acquiring or transmitting HIV, especially as resistant
strains of the virus emerge.
When counseling about dual method use, the provider is responsible for helping clients
determine what method(s) will be effective for them and how confident they are that a
partner will use condoms. Providers must also help clients consider what adjustments
may need to be made over time because as personal situations change, a client’s need for
protection may change as well.
Because clients often find it difficult to negotiate condom use with their partners, it is
important for providers to teach skills for negotiation of condom use and the correct use
of condoms. This is typically done using demonstrations and role-plays to simulate some
of the more challenging obstacles clients may encounter when negotiating with their
partners. When possible and with the client’s consent, partner or couple counseling on the
importance of condom use can also be an effective approach.
Men who may have intercourse with multiple partners should be counseled to use
condoms even when a female partner is using another method of contraception. The
advice to use condoms in addition to another method is particularly important for
discordant couples. However, concordant couples, where both partners are HIV-positive,
should also use condoms to avoid STIs and superinfection with another HIV strain.
Encourage dual method use for all clients with HIV who wish to protect themselves.
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Instructions for Using Male Condoms
Remember: To provide effective contraception and protection against STIs, condoms must be
used with every act of sexual intercourse. Just one unprotected act can lead to pregnancy or
sexually transmitted infection. Keep an adequate supply of condoms available at all times.
1. Use a new condom for each act of sexual intercourse.
 Check the expiration or manufacturing date. Male condoms
should be used within five years of the manufacturing date.
 Open the package carefully by tearing the notched edge. Do not
use teeth or sharp objects to open the package.
2. Put the condom on the erect penis before the penis touches the
vagina.
 Ensure that the rolled edge (rim) is on the outside of the
condom. Unroll the condom slightly to make sure it unrolls
properly.
3. Place the condom on the tip of the erect penis and unroll it.
 Unroll the condom all the way to the base of the penis.
The condom should unroll easily. If it does not, it is probably
backwards – do not turn it over and try again. Throw it away
and start with a new one.
Lubricants used with latex condoms should be water-based.
Good lubricants include glycerine and specially made
products. Lubricants help prevent tearing the condom during
intercourse.
4. After intercourse, remove the condom.
 After ejaculation, hold the rim of the condom at the base of
the penis so it will not slip off. Remove the penis from the
vagina while the penis is still erect.
 Remove the condom without spilling semen on the vaginal
opening.
5. Dispose of the condom safely.
 Wrap the condom in its package or in a tissue and put it in
the rubbish or a pit latrine. Do not put the condom into a
flush toilet. Do not leave it where children will find it and
play with it. Do not use a condom more than once.
If a condom breaks:
To prevent pregnancy, start a course of emergency contraception as soon as
possible, and no later than five days after intercourse. If there is a high risk
for HIV infection, postexposure prophylaxis with antiretroviral drugs is
available in some areas. To be effective, PEP drugs must be started as soon
as possible after exposure. Postexposure prophylaxis does NOT provide
complete protection from HIV infection.
Illustrations: Essentials of Contraceptive Technology, 1997.
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Tips on Caring for Male Condoms – Special Handling Instructions
1. Store condoms in a cool, dark place. Heat, light, and humidity damage condoms.
2. Handle condoms carefully. Fingernails and rings can tear them.
3. Do not unroll condoms before use. This may weaken them. Also, an unrolled
condom is difficult to put on.
4. Always use a new condom if the one you have:
 has torn or damaged packaging;
 has a manufacturing date on the package that is more than five years past;
 is uneven or has changed in color;
 feels brittle, dried out, or very sticky.
5. Use additional water-based lubrication to prevent condom breakage.
Tips on Reducing Male Condom User Error
Misuse of condoms, rather than poor condom quality, accounts for the majority of
breaks and slips. Most users rarely experience breaks or slips. Condom effectiveness
depends heavily on the user’s skills and experience.
Common errors that increase the risk of pregnancy and STIs include:
 Failure to use condoms with every act of intercourse
Non-use accounts for most pregnancies attributed to condom use.

Failure to use condoms throughout intercourse
Some men put condoms on after starting intercourse or may remove condoms before
ejaculating. This increases the risk of pregnancy or STIs. In one study, men acquired
gonorrhea despite using condoms because they failed to put the condom on before
starting intercourse. Condoms must be used every time from “start to finish.”

Improper lubricant use with male condoms
Unlike water-based lubricants (e.g., K-Y Jelly), oil-based lubricants (e.g., petroleum
jelly, baby oil, and hand lotions) weaken latex condoms and increase breakage. Some
people use oil-based products as condom lubricants, mistaking them for water-based
lubricants because they readily wash off with water.
Note: Vaginal medications (e.g., for yeast infections) often contain oil-based ingredients
that can damage latex condoms.

Incorrect placement of the condom on the penis
Condoms may tear if men are not careful when removing the condom from the package.
Some men accidentally place the condom upside-down on the penis, then flip the condom
over and use it for intercourse, a practice that may expose their partner to pre-ejaculatory
fluid or infectious secretions. Although pregnancy is unlikely to result from exposure to
pre-ejaculate, HIV has been detected in pre-ejaculatory fluid.

Poor withdrawal technique
Slippage during withdrawal, one of the most common reasons for condom failure, may
be prevented if the condom’s rim is held at the base of the erect penis while withdrawing
after ejaculation. One study found only 71 percent of men held the rim during
withdrawal and only 50 percent withdrew immediately after ejaculation.

Failure to the check expiration or manufacture date and the quality of condoms
Condoms should not be used after their expiration date (printed on the packaging). Users
should check that condoms are sealed; and that there are no cracks, holes, or other damage.

Failure to store condoms properly
Heat damages condoms; therefore, they should never be stored in hot places (e.g., in
direct sunlight or in pockets of tight jeans).
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Instructions for Using Female Condoms
Check the expiration or manufacture date on the
package. Female condoms should be used within
five years of the manufacturing date.
Open the package carefully. It should be torn at the
notch at the top right of the package. Do not use
teeth or sharp objects to open the package.
Examine the condom to make sure that it is suitably
lubricated.
While holding the sheath at the closed end, grasp
the flexible inner ring and squeeze it with the
thumb and second or middle finger so it becomes
long and narrow.
Choose a position that is comfortable for insertion:
squatting, raising one leg, sitting, or lying down.
With the other hand, separate the outer lips of the
vagina.
Gently insert the inner ring into the vagina. Feel the
inner ring go up and move into place.
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Place the index finger on the inside of the condom,
and push the inner ring up as far as it will go. Be sure
the sheath is not twisted. The outer ring should remain
on the outside of the vagina.
The female condom is now in place and ready for use
with a partner.
When you are ready, gently guide your partner’s penis
into the sheath’s opening with your hand to make sure
that it enters the condom. Be sure that the penis is not
entering on the side, between the sheath and the
vaginal wall. Use enough lubricant so that the condom
stays in place during sex.
If the condom is pulled out or pushed in, there is not
enough lubricant. Add more to either the inside of the
condom or the outside of the penis.
To remove the condom, twist the outer ring and gently
pull the condom out. Try to do this before standing up
to avoid spilling any semen.
Wrap the condom in its package or in a tissue and put
it in the rubbish or a pit latrine. Do not put the condom
into a flush toilet. Do not leave it where children will
find it and play with it.
Source: The Female Condom: A Guide for Planning and Programming, WHO and UNAIDS, 2000.
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Negotiating Safer Sex
Instructions: Use the blank spaces to write in additional excuses and possible responses.
Steps for Negotiating for Safer Sex
1. Decide what you want and what you are willing to offer in return.
2. Focus on safety rather than blame or lack of trust.
3. Use other people as examples. If others are doing it, it is more acceptable.
4. Ask for help if you need it. A trusted person can facilitate difficult partner discussions.
Things Reluctant Partners May Say
 It will not feel as good.
Responses to Use During Negotiation
 It may feel different, but it will still feel
good. Here let me show you.
 You can last even longer and then we will
both feel good.

 I do not have any diseases!
 I do not think that I have any either. But one
of us could and not know it.

 You are already using a family planning
method.
 I would like to use a condom anyway. One
of us might have an infection from before
that we did not know about.
 It will enhance the pregnancy prevention of
the other method.

 Just this once without a condom.
 It only takes one time without protection to
get an STI or HIV. And I am not ready to be
pregnant.

 Condoms are for prostitutes.
Why do you want to use one?
 Condoms are for everyone who wants
protection. No condoms, no sex!
 Condoms are for people who care for each
other; I care for you and you care for me.





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SESSION 7: Hormonal Methods and Theoretical Concerns
Hormonal contraceptives include combined oral contraceptive pills that contain the
hormones estrogen and progestin, and a group of methods that contain only progestin
and no estrogen. This group includes progestin-only oral contraceptive pills, or POPs;
injectables such as Depo-Provera (also known as DMPA); and implants such as
Norplant, Jadelle, Sinoplant, and Implanon.
Hormonal methods are appropriate for women with HIV, and most offer excellent
pregnancy protection. Pregnancy rates for injectables and implants are less than onehalf percent in both perfect and typical use. Oral contraceptives can also be very
effective when women remember to take pills on schedule.
Hormonal methods are easy to use, especially injectables and implants, which require
very little action on the part of the client. Implants offer long-acting protection for up
to five years, while other methods are suitable for both short- and long-term use. All
hormonal methods are reversible, although fertility return with DMPA may take
somewhat longer than with other methods.
All hormonal methods offer some health benefits, including but not limited to reduced
risk of reproductive tract cancers, anemia, and clinical pelvic inflammatory disease. In
addition, serious complications are extremely rare with hormonal methods, especially
if women meet the eligibility criteria for initiating use.
While hormonal methods are appropriate for women with HIV, several biological
concerns regarding the relationship between hormonal contraceptives and HIV exist.
These concerns continue to be an important area of research, as new evidence
becomes available, changes to some existing family planning practices may be
warranted.
Theoretical Concerns about Hormonal Methods
? ? ?
Some antiretroviral drugs can reduce or increase blood levels of
??
contraceptive hormones. (Leitz, 2000; Piscitelli, 1996) Theoretically,
lower concentrations could reduce the effectiveness of hormonal
4
contraceptives, while higher concentrations could increase hormonerelated side effects. Similarly, contraceptives may affect the efficacy of some ARV drugs.
Other issues that require further research include possible effects of hormonal
contraception on HIV-positive women’s infectivity and possible relationships
between hormonal contraception and HIV disease progression.
It is important to balance these concerns, which are primarily theoretical, against the
real risk of unintended pregnancy and its impact on maternal and infant morbidity and
mortality.
How ARVs Interact with COCs
A few, small pharmacokinetic studies have examined the use of certain ARV
therapies with limited courses of combined oral contraceptives. These studies showed
both positive and negative effects on hormone levels.
The main concern about COCs is that some ARVs affect liver enzymes, which then
speed up liver metabolism of contraceptive hormones and could lower blood levels of
the hormones. The reduced concentrations of contraceptive hormones in blood
theoretically may lead to reduced effectiveness of hormonal contraceptives and
increased risk of pregnancy.
Participant Manual: Contraception for Clients with HIV Curriculum
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Not all classes of ARVs interact with contraceptive hormones because not all ARVs
affect liver enzymes. Drugs that do not affect liver enzymes, and therefore probably
do not affect hormonal contraceptives, include NRTIs. Drugs that affect liver
enzymes include NNRTIs some of which may reduce blood concentration of
contraceptive hormones by approximately 20 percent, and ritonavir-boosted protease
inhibitors which may reduce concentrations of contraceptive hormones by as much as
40 percent. The charts below summarize what is known to date.
Interactions between COCs and PIs
Protease inhibitors
Contraceptive hormone
levels in blood
ARV levels
in blood
Nelfinavir (NFV)

No data
Ritonavir (RTV)

No data
Lopinavir (LPV)/
Ritonavir (RTV)

No data
Atazanavir (ATV)

No data
Indinavir (IDV)

No data
Saquinavir (SQV)
No data
No change
Concerns about interactions with hormonal contraceptives focus on protease
inhibitors (PIs) and NNRTIs. The chart above summarizes the interactions that were
observed in the levels of contraceptive steroids and PIs. Notice that in some cases the
contraceptive steroid levels decreased while in other cases, they increased.
Limited evidence suggests that ritonavir-boosted protease inhibitors decrease blood
concentrations of contraceptive hormones by as much as 40 percent. Although there is
no evidence yet of the clinical significance of this interaction, scientists believe that
this level of reduction in the blood concentration of contraceptive hormones is likely
to reduce the effectiveness of oral contraceptives. In contrast, an increased level of
contraceptive hormone may theoretically increase the risk of side effects associated
with hormonal contraceptives.
At this time, there is not sufficient data on how blood levels of protease inhibitors
may be affected by contraceptive hormones among women who take COCs.
(WHO, 2004; Ouellet, 1998; University of Liverpool, 2008)
Interactions between COCs and NNRTIs
Non-nucleoside reverse
transcriptase inhibitors
Contraceptive hormone
levels in blood
ARV levels
in blood
Nevirapine (NVP)

No change
Efavirenz (EVF or EFZ)

No change
The chart above shows the effects that were observed in the levels of contraceptive
steroids and NNRTI drugs when they are taken concurrently. In the case of
nevirapine, one study demonstrated a 20 percent decrease in plasma concentration of
hormonal contraceptives among women taking concurrent estradiol/norethindrone and
Participant Manual: Contraception for Clients with HIV Curriculum
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nevirapine. While clinical significance of such interaction is unclear, we do know that
ultra-low-dose, 20 microgram, oral contraceptives – which contain two-thirds the
amount of estrogen found in regular low-dose oral contraceptives – are widely used in
countries where they are approved, and highly effective if taken correctly.
In the case of efavirenz, an increase in plasma concentration of hormonal
contraceptives was observed. No changes in the blood concentrations of the ARV
drugs were found.
Although most of the existing research examines the interaction between ARV drugs
and combined oral contraceptives, there is limited research that looks at interactions
between ARV drugs and DMPA. Based on information currently available, no
significant interaction was found between ARV drugs and progestin-only injectables
particularly DMPA. (WHO, 2004; Cohn, 2005)
Clinical Significance of COC/ARV Interaction Is Unknown
Currently, concerns about reduced effectiveness of hormonal contraceptives due to
interactions with ARV drugs are based on blood levels of contraceptive hormones and not
on clinical outcomes, such as pregnancy rates or indicators of ovulation. Additionally,
while there is limited evidence on COCs and DMPA, no studies have been completed to
clarify possible interactions between ARVs and other hormonal contraceptives, including
combined injectables, vaginal rings, patches, progestin-only pills, emergency
contraceptive pills, progestin implants, or progestin intrauterine systems.
It is unlikely that the effectiveness of contraceptive methods is appreciably affected
when the blood levels of the hormones are only somewhat reduced, as in the case of the
NNRTI, nevirapine. However, with ritonavir-boosted protease inhibitors, the reduction
is considered significant enough to decrease contraceptive effectiveness. This is why
the 2008 WHO working group decided that ritonavir-boosted protease inhibitors
generally should not be used by women taking oral contraceptives or combined
injectables. For other types of ARVs, more restrictive changes to clinical guidelines will
not be considered unless there is sufficient evidence that the interaction increases the
risk of contraceptive method failure. It is important to realize that ritonavir-boosted
protease inhibitors are not currently recommended by WHO as part of a first-line ARV
regimen and thus are not as commonly used as other ARV drugs.
Hormonal Use – Increases Risk of Cervical Infection
It appears that use of hormonal contraceptives may increase the risk of acquiring
cervical STI infections, which, as you will see on the next several slides, may have
some implications for women with HIV. A ten-year prospective study of HIV-positive
Kenyan sex workers found that use of hormonal contraceptives was associated with a
significantly increased risk of cervical chlamydial infection and cervicitis, even after
controlling for demographic factors and sexual behavior. Compared to women who
used no hormonal contraceptives, women using DMPA had a threefold increased
incidence of cervical chlamydial infection and a 1.6-fold increased incidence of
nonspecific cervicitis. Women using oral contraceptive pills had more than double the
increased incidence of nonspecific cervicitis. Use of hormonal contraceptives was not
associated with an increased incidence of gonorrhea infection, however. (Lavreys, 2004)
Hormonal Use – May Increase HIV Shedding
A theoretical concern also exists that hormonal contraceptive use by women with HIV
could increase HIV shedding, therefore increasing risk of HIV transmission to an
uninfected partner. However, data are conflicting about such a relationship. Some
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studies showed no increase in HIV shedding. Other data suggest that more HIV
shedding does occur when women are using hormonal contraception. (Wang, 1999)
One prospective study conducted among family planning clients in Mombasa, Kenya,
detected a modest but statistically significant increase in cervical shedding of HIVinfected cells. Cervical shedding in women with HIV rose from 42 percent to
52 percent after initiation of various hormonal contraceptives. However, no difference
was detected in the amount of cell-free virus in genital secretions. (Wang, 2004)
The relative impact of HIV-infected cells versus cell-free virus on infectivity is
uncertain. The presence of both in maternal cervical secretions and in breast milk has
been found to increase the risk of vertical transmission. (John, 2001)
Relationships between Hormonal Contraceptive Use and HIV
It appears that
use of hormonal
Cervical STI infections
may also increase
contraceptives
• risk of acquiring cervical shedding of HIV
may increase the
cervical STIs
risk of acquiring
• cervical shedding
STIs and the
of HIV
cervical
shedding of HIV. It is also known from research studies that cervical STIs increase
HIV shedding in cervical secretions, even in women who are not using hormonal
contraceptives. (McClelland , 2001; Ghys, 1997) The increased amount of virus may in turn
increase the risk of HIV transmission to a sexual partner. While some concern about an
increased risk of HIV transmission among users of hormonal contraceptives is
warranted, more data are needed before any changes to current service delivery
guidelines are considered.
Using hormonal
contraceptives may
increase:
More HIV virus may
increase risk of
transmission to
partner
Hormonal Use and Disease Progression – Requires Further Research
Some studies have also raised concerns that hormonal contraceptives may affect
disease progression in women with HIV. In a prospective cohort study of HIV
acquisition among 1,337 sex workers in Mombasa, Kenya, the use of DMPA at the
time of HIV infection was associated with a higher viral load set point.
Viral load set point is an important indicator of HIV disease progression. As
illustrated in the graphic below, after a person initially becomes infected, his or her
viral load increases. The killer cells of the immune system respond to the HIV virus
by attacking infected cells, lowering the viral load to a certain level. This level is
known as the viral set point. The higher the viral load set point, the faster HIV-related
deterioration of the immune system occurs. Thus, the Mombasa study findings
suggest that DMPA use may hasten the natural course of HIV infection. (Lavreys, 2004)
Viral load increases
after initial infection
Immune system’s
killer cells respond
Viral load is reduced
Higher set point
Lower set point
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Similarly, Kenyan sex workers using hormonal contraceptives near the time of HIV
acquisition were more likely to be infected with multiple genetically diverse subtypes
of the same virus than sex workers not using hormones. Infection with multiple
subtypes appears to be related to a higher viral set point and to faster CD4 decline,
which is another key indicator of HIV disease progression. (Sagar, 2003)
Many of the studies on hormonal contraception and HIV disease progression have
been conducted among sex workers in Kenya, and some of the findings have not been
corroborated by other studies. Therefore, further research among other populations of
women in other geographic locations is needed before any changes to service
provision guidelines are made.
Hormonal Use and HIV – What Providers Should Do
Given what is currently known about hormonal contraception and HIV, providers should:
• Counsel their clients that certain ARV drugs reduce the blood concentration of
contraceptive hormones, which theoretically may reduce the effectiveness of hormonal
contraceptive methods – with the exception of DMPA.
•
Encourage clients to always tell their health care providers which medications they are
taking. Although a client may not currently be using any drugs that compromise method
effectiveness, at some point she may need to switch contraceptive methods to be eligible
for other treatment regimens, for example, if ritonavir is added to her ARV regimen.
•
When possible, prescribe ARV drugs that do not interact with hormonal contraceptives.
•
If this is not possible, encourage women to be very careful about using the methods
correctly and consistently, and to consider using condoms for additional protection.
•
Keep abreast of updates to clinical practice guidelines. As new research on these and
other related topics becomes available, technical experts and policy-makers will make
appropriate changes to clinical practice guidelines. For example, the available research on
HIV disease progression and possible increased risk of transmission among hormonal
contraceptive users is not conclusive. Until additional research on these topics can
provide decisive information, there is no reason to change clinical practice or to counsel
clients about these theoretical concerns.
Counseling Messages for Women Using Hormonal Contraception and ARV Therapy
•
Some ARV drugs have the potential to reduce effectiveness of hormonal contraceptives;
this is why it is especially important to use hormonal methods correctly when on ART.
•
Women taking COCs need to take the pills on schedule without missing any. If a
woman is prescribed ritonavir as part of her ARV regimen, she should talk with her
provider about using a method other than COCs. This is because the effectiveness
of COCs may be significantly reduced by ritonavir.
•
Women on NET-EN need to return for the next injection on time. Although
normally the next injection can be given as much as two weeks late; in the presence
of ARV therapy, it is safer to closely follow the recommended injection schedule.
•
Women should consider using condoms to ensure additional protection from
pregnancy because the effectiveness of hormonal contraceptives – other than
DMPA which provides a wide margin of effectiveness in each dose – may be
compromised by ARV therapy. Focusing on the pregnancy prevention role of
condoms may help when negotiating condom use with a partner.
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Oral Contraceptives – Note-taking Pages
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Injectable Contraceptives – Note-taking Pages
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Implants, POPs, and Emergency Contraception – Note-taking Pages
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SESSION 8: Intrauterine Devices (IUDs)
The IUD, also known in some places as the intrauterine contraceptive device or IUCD, is
one of the world’s most widely used family planning methods. It is the second most
commonly used form of contraception, with the first being female sterilization. The IUD is
the most common form of reversible contraception, used by about 100 million women
worldwide. Currently, sixty-seven percent of IUD users live in China. However, IUD
acceptance is growing in other parts of the world.
Most IUDs being inserted today are shaped like a T with copper wires or bands on the
plastic stem and arms. In the late 1960s, researchers found that adding copper to the plastic
frames made IUDs more effective than earlier devices. The copper released into the
uterine cavity increases the contraceptive efficacy of the IUD.
The IUD is inserted into a woman’s uterus through her vagina and then cervical opening.
Almost all brands of IUD have one or two strings tied to them. The strings hang through
the opening of the cervix into the vagina. The user can check that the IUD is still in place
by touching the strings. A provider can remove the IUD by pulling gently on the strings
with forceps.
Among copper IUDs, the TCu-380A is currently one of the most widely used in the world.
Less widely available are hormonal IUDs that steadily release small amounts of progestin,
such as levonorgestrel. The information in this manual focuses on the TCu-380A IUD.
IUDs Safe for Women with HIV
Research has found that women with HIV can use IUDs safely. A study conducted in
Kenya examined over a two-year period the health of two groups of women who received
an IUD: 486 women who were HIV-negative, and 150 women with HIV infection.
Researchers looked for problems after insertion, such as IUD removal due to infection,
bleeding, and pain; IUD expulsion; pregnancy; and pelvic inflammatory disease.
As shown in this chart, the
percentage of women
Overall complications
reporting complications after
Little
difference
Little
difference
IUD insertion was almost
IUD removal
in complications
in complications
identical for the two groups –
between
IUD
between IUD
acceptors with
IUD expulsion
14.7 percent among women
acceptors
with
and without HIV.
with HIV and 14.8 percent
and without HIV.
Pregnancies
among women without HIV.
The percentage of women
PID
reporting problems related to
Noninfected N=486
HIV-infected
N=150
Infection-related
some type of infection,
complications
including pelvic tenderness
0
20
40
60
80
100
and IUD removal for
Percentage of women in Kenyan study
infection or pain, was 10.7
percent among those who were HIV-infected and 8.8 percent among those who were HIVfree. While women with HIV tended to have slightly more problems related to infection,
they were not significantly different from women in the noninfected group. (Morrison, 2001)
14.8
14.7
8.6
10.0
4.9
2.7
0.8
0
0.4
2.0
8.8
10.7
In short, little difference in side effects and infection-related complications was seen
between HIV-infected and noninfected IUD acceptors. Overall, 85 percent of women had
no problems with IUD use. These findings suggest that the IUD is an appropriate
contraceptive method for women with HIV. This is especially true for women who want to
limit births for an extended period of time or where access to sterilization services might
be limited.
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IUD Use Does Not Increase Cervical Shedding of HIV
A theoretical concern about IUD use by women with HIV is that it could increase cervical
shedding of HIV, thus increasing the risk of transmission to a sexual partner. In a study
conducted in Kenya, researchers calculated rates of cervical shedding of HIV-infected cells
before IUD insertion and four months after insertion. Results showed no significant
differences in cervical shedding among women with HIV before and after insertion. In other
words, current evidence suggests that IUDs do not raise the amount of virus to which a
woman’s sexual partner is exposed. (Richardson, 1999)
Reducing the Risk of Pelvic Inflammatory Disease
Pelvic inflammatory disease (PID) is an infection of a woman’s upper genital tract.
Overall risk of PID associated with the IUD is very low, although there is a somewhat
increased risk of PID during the first 20 days after insertion. Sexually transmitted
infections (STIs), such as gonorrhea and chlamydia, are the reason some women develop
PID. When the IUD is inserted through an infected cervix, there is a chance that it will
carry the infection from the lower to the upper genital tract. However, women with
undiagnosed and untreated gonorrhea or chlamydia who are not using the IUD develop
PID as well. Based on available evidence, it appears that PID rates are similar among
women with STIs with or without the IUD being inserted, and the IUD itself contributes
very little to the risk of PID. (Shelton, 2001)
An IUD user’s risk for developing PID can be reduced even further if providers follow
important guidelines. Screen women for risk of STIs. While women at risk of STIs can
generally use an IUD, more careful follow-up after insertion may be recommended.
However, providers should try to screen out women at high individual risk of STIs. This
category of women may include those with more than one sexual partner, those whose
partner has multiple sex partners, or those whose partners have symptoms of STIs.
Carefully screen women for any symptoms and signs of current STIs. In many cases, good
clinical judgment is sufficient to rule out an infection with gonorrhea and chlamydia.
Ruling out the possibility of a current STI by medical history and physical examination is
essential prior to providing the IUD. Laboratory tests are not required prior to IUD
insertion, but they could be offered when available and when the provider has difficulty
ruling out an infection by clinical judgment alone. IUDs should never be inserted in
women with current STIs. Women at high individual risk of STIs should generally not
have an IUD inserted unless other methods are unavailable or unacceptable to the client
and careful follow-up is possible.
Counsel all users about the risks of PID. Emphasize that behaviors that place a woman at
greater risk for STIs also increase her risk of PID.
Strictly follow infection prevention procedures to reduce the risk of introducing bacteria
into the uterus. Antibiotic prophylaxis at the time of IUD insertion is generally not
recommended. However, in settings where the prevalence of cervical gonococcal and
chlamydial infections is high and screening for STIs is limited, prophylaxis may be
considered.
Most service delivery guidelines recommend that the client return after the first the menses
or about three to six weeks after the IUD is inserted to check for the presence of infection.
Advise the client to return immediately if she experiences symptoms, such as fever or low
abdominal pain, during the first month after insertion. (World Health Organization, 2004)
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SESSION 9: Sterilization, FAB Methods, LAM and
Infant Feeding
Male and Female Sterilization – Counseling is Especially Important
For women and couples with HIV who have decided to have no more children, female or
male sterilization may be a good option. As with any family planning method, it is
essential that the client be free to exercise an informed, voluntary choice. Even the mildest
forms of pressure must be avoided. Providers should give appropriate information about
all available contraceptive options and give the preferred method if possible.
Providers should take special care with clients interested in sterilization and carefully discuss
the decision to end fertility. Clients who consider sterilization should have a thorough
understanding of the alternative long-acting methods available. If a client has any doubts, it is
best to recommend delaying the procedure and encouraging the use of other contraceptive
methods until a clear decision is made.
Counselors should also:
• Inform clients about possible complications of sterilization procedures. Such
complications are infrequent, but they do occasionally occur and may include infection or
bleeding, and in the case of female sterilization, adverse reaction to general anesthesia (in
the cases where conditions or circumstances prevent the use of local anesthesia).
• Clarify that unlike some other contraceptive methods, sterilization has no systemic side effects.
• Explain time-to-effectiveness. While female sterilization is effective immediately,
male sterilization is not. Because it takes time for the vas to become completely clear
of sperm, couples should be counseled to use another contraceptive method for 12
weeks – three months – following vasectomy. Although guidelines have typically
recommended a waiting period of 12 weeks or 20 ejaculations, recent research has
shown that the 12-week waiting period is significantly more reliable. The success of
vasectomy also may be determined by sperm analysis, if available.
• Discuss the lack of STI/HIV protection. Providers can help clients to assess their risk of
STI/HIV transmission and encourage those at risk to use condoms in addition to sterilization.
The WHO Medical Eligibility Criteria state that there are no medical reasons to deny
sterilization to a client with HIV. If a woman or man has an acute AIDS-related illness,
sterilization should be delayed until the condition has improved. Because sterilization is a
surgical procedure, any acute HIV-related opportunistic infection may complicate or prolong
recovery. Because neither male nor female sterilization offers protection from STIs/HIV,
couples should be counseled about condom use for STI/HIV prevention.
Dispelling Myths and Misunderstandings
A number of myths and misunderstandings exist regarding female and male sterilization.
Some women fear that sterilization will cause them to be less feminine or lose their sexual
desire. However, sterilization does not affect appearance or normal sexual function in any
way. Some women may even feel their sexual desire increase because they are no longer
worried about becoming pregnant. Another myth is that eggs will build up in the body.
Sterilized women continue to produce eggs, but the eggs degenerate and are reabsorbed.
Women need to understand that after sterilization, menstruation will still occur as
previously, although it no longer signals fertility. Also, women may falsely believe that
the tubes can be simply united to restore fertility. Reversal is a very complex and
expensive procedure that is rarely available, and success is not guaranteed.
In the case of male sterilization, many men incorrectly equate vasectomy with castration –
the physical removal of the testes – and a loss of sexual desire. However, male sterilization
is not castration and does not affect normal sexual function or the quantity of ejaculate.
Some men may falsely believe that vasectomy will cause them to lose male physical traits
or strength. However, after vasectomy the production of hormones related to sexual
behavior and physical traits remains the same. Another common misconception is that
sperm will build up in the body. As with female eggs, sperm do not build up in the body
but are reabsorbed on a continual basis.
Participant Manual: Contraception for Clients with HIV Curriculum
page 68
Sterilization – Note-taking Pages
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Fertility Awareness-based Methods – Note-taking Pages
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Participant Manual: Contraception for Clients with HIV Curriculum
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Lactational Amenorrhea Method (LAM) and Infant Feeding Options
The lactational amenorrhea method, also known as LAM, is
a temporary contraceptive option used for up to six months
postpartum by women who are fully or nearly fully breastfeeding and who continue to have no menses. It is safe,
convenient, and highly effective. Women who meet all three
criteria for using LAM have only a 1 to 2 percent chance of
getting pregnant. If any one of the criteria changes, another
FP method must be initiated to avoid unintended pregnancy.
LAM is effective if all
three criteria are met:
• woman is exclusively
breastfeeding
• infant is less than
six months old
• menstrual periods
have not returned
Recommended Breastfeeding Behaviors
One of the keys to successful use of LAM is maintaining breastfeeding practices that will
ensure LAM’s success. Providers should emphasize the following optimal breastfeeding
practices to the mother:
•
•
•
•
•
Breastfeed as early as possible after delivery. This immediate gratification for the
infant establishes a behavior, breastfeeding, which is easily reinforced. A delay of even
a few hours can hinder the successful establishment of
breastfeeding.
Breastfeed without supplements until the infant is
about six months of age. This will help to prolong the
period of lactational amenorrhea.
Breastfeed frequently, on request, not on schedule.
A baby will seek as much breast milk as he or she
needs. A fixed feeding schedule can be difficult to
maintain due to changing nutritional needs and this
can frustrate both the mother and the baby.
Avoid long intervals between feedings. If the mother
and the baby are regularly separated for four to six
hours or more, the duration of lactational amenorrhea will decrease. For this reason,
breastfeeding at night must be maintained.
Avoid using pacifiers and bottles if you give the baby expressed milk. Pacifiers
diminish a baby’s need to suckle for comfort. Bottle use may confuse the infant and
can lead the baby to reject the breast. Bottle use also increases the risk of gastric
infection; feeding expressed breast milk by cup and spoon is preferable.
Factors that Increase Transmission of HIV to Infant during Breastfeeding
There are specific factors that may put a woman at higher risk of transmitting HIV to her
infant during breastfeeding. One factor is the amount of HIV virus in the mother’s blood
and breast milk, known as the viral load. The risk of transmission is greatest when the
viral load is high, which is often the case with recent HIV infection or advanced HIV and
AIDS. Other factors include:
• duration of breastfeeding – the longer the mother continues to breastfeed, the higher
the chance of HIV transmission.
• mixed feeding, such as foods or fluids in addition to breast milk.
• breast abscesses, nipple fissures, mastitis – all may increase a baby’s exposure to HIV.
• poor maternal nutrition status – may affect the strength of the immune system and lead
to a higher viral load.
• oral disease in the infant, such as thrush or sores.
For more information, see Fact Sheet 8. HIV and Breastfeeding, page 117.
Participant Manual: Contraception for Clients with HIV Curriculum
page 73
LAM and Infant Feeding Options – Note-taking Pages
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Participant Manual: Contraception for Clients with HIV Curriculum
page 76
SESSION 10: Integrating FP into HIV Services for
Provision of Contraceptive Information, Counseling, and
Methods
To make the process of integration manageable and practical, consider the range of levels
for integrating FP into HIV services. FP services that are integrated with HIV care and
treatment services need to be appropriate to the setting and resources. Facilities and
programs can aim for a progressive range of integrated services, depending on their
capabilities and resources.
The chart below is a program model of five possible levels for integrating FP with HIV
services. These levels of integrated services can be offered through mobile service
mechanisms, and Levels A through C can be offered by community- or home-based
personnel. Refer to the source document for detailed descriptions of service cadres and
tasks for each integration level.
Level A
Provides all of the
following functions:
Provides FP
information to clients
accessing ART,
PMTCT, STI, VCT,
and tuberculosis
services.
Performs risk/intention
assessment for
pregnancy or spacing.
Counsels on FP
methods, methods’
ability to prevent STI
and HIV infection,
method choices
available and where to
access, dual
protection, and
potential drug
interactions with
hormonal methods.
Level B
Level C
Level D
Level E
Provides all
Level A
functions plus:
Provides all
Level B
functions plus:
Provides all
Level C
functions plus:
Provides all
Level D
functions plus:
Provides oral
contraceptives*
with instructions
for use.
Provides
injectable
contraception,
with instructions
for use, and with
caution to return
on schedule for
reinjection
without delay.
Provides
intrauterine
device (IUD),
with instructions
for use.
Provides surgical
contraceptive
methods, with
instructions for
self-care, and
provides followup.
Provides followup or refers for
follow-up.
Counsels on
potential drug
interactions
with oral
contraceptives.
Provides followup or refers for
follow-up.
Provides implant,
with instructions
for use.
Provides followup or refers for
follow-up.
Provides condoms,
instructs for and
demonstrates correct
use.
Provides emergency
contraceptive pills.*
Refers for other
methods not offered
on-site.
* If facilities or programs providing Level A functions are not immediately prepared to provide oral
contraceptives for ongoing users, they may provide emergency contraceptive pills with referral for
ongoing FP management. If the facility or program already provides oral contraceptives (Level B), it can
also offer emergency contraceptive pills.
Source: Farrell BL. Family Planning – Integrated HIV Services: A Framework for Integrating Family Planning
and Antiretroviral Therapy Services. New York: EngenderHealth, 2007.
Participant Manual: Contraception for Clients with HIV Curriculum
page 77
Examples of FP Integration with RH Services
The table below contains suggestions for how FP can be integrated into existing RH services.
During any and every client encounter, consider the client’s risk for unintended pregnancy, STI, HIV,
and other preventable infections and problems that negatively impact maternal and child health.
HIV services (e.g., VCT, ART):
 Include assessment of client’s fertility desires in VCT activities.
 Provide information about FP and its role in protecting against sexual transmission of HIV,
against mother-to-child transmission of HIV, and in supporting effective ART.
 Promote dual protection.
 Provide information on locations for FP services.
 Provide FP methods to the capacity of the sites.
 Facilitate referrals for FP services (e.g., long-acting and permanent methods).
 Assess FP use or continuation during ART.
 Counsel clients on ways to ensure contraceptive effectiveness in the presence of possible
drug interactions.
 Inform clients on option and availability of emergency contraception.
Management of Opportunistic Infections (OIs):
 Include assessment of FP method use for developing the treatment plan for OIs.
 Counsel clients on ways to ensure contraceptive effectiveness in the presence of possible
drug interactions.
 Provide referral or FP counseling and method if client does not desire a pregnancy.
Postabortion Care:
 Establish staff presence, skill, and availability to provide FP counseling, method provision,
and referral before discharge from postabortion care.
 Include dual-protection counseling in client counseling.
 Explore client’s risk for STIs and HIV during FP counseling, to appropriately refer for VCT
as a preventive measure against HIV infection and to prevent MTCT in a subsequent
pregnancy.
Antenatal Care (e.g., PMTCT, malaria prevention, and management):
 Promote VCT to plan for positive maternal and child health outcomes in the presence of HIV
infection, in the context of informed choice.
 Promote VCT to develop strategies for HIV-negative women to remain uninfected.
 Promote benefits of spacing pregnancies for maternal and child health.
 Counsel on methods available immediately postpartum (lactational amenorrhea method, IUD,
condoms, voluntary sterilization).
 Maintain follow-up through FP or child health services for women to continue with their
postpartum method or access another ongoing method (e.g., transition from the lactational
amenorrhea method to another FP method).
 Teach newly delivered women correct techniques of breastfeeding to maintain intact nipples
(and thus prevent HIV transmission through broken skin and blood) and stimulate an
adequate supply of breast milk.
 Provide condoms for use during the antenatal and postnatal period.
 Provide informed consent counseling for immediate postpartum tubal occlusion and
postpartum IUD, where available.
 Assess risk of malaria and counsel about risk during pregnancy with or without HIV;
counsel to develop prevention strategies and treat aggressively to prevent anemia.
Participant Manual: Contraception for Clients with HIV Curriculum
page 78
Postnatal Services (e.g., immediately, at 2 weeks, and at 4 to 6 weeks):
 Provide postnatal FP counseling and provision of methods that support exclusive
breastfeeding.
 Provide immediate postpartum tubal ligation.
 Provide immediate postpartum IUD.
 Provide postnatal FP counseling and methods that do not compound anemia and do not
inhibit lactation.
 Monitor client success with FP methods during the immediate postnatal period and assess
client’s risk for STIs and HIV.
 Promote VCT for health and fertility management planning.
 Include dual-protection information during client counseling.
Fistula Services:
 Include assessment of the client’s fertility desires in postoperative fistula repair counseling,
as well as at discharge and during follow-up.
 Provide FP counseling to assist the client or couple to achieve fertility desires, including
dual-protection information and information on the necessity to abstain from sexual
intercourse for three months postoperatively.
 Provide the client’s chosen method, including condoms, where appropriate and accepted (or
facilitate referrals for FP methods not available at the fistula repair facility).
 Monitor the client’s success with FP methods during the fistula rehabilitation period.
 Facilitate referrals for FP methods not available at fistula repair sites.
 Incorporate FP information during fistula-prevention outreach activities, include when
referring to FP services facilities (public or private) and community-based providers.
 Include information to clients on emergency contraception during fistula-prevention outreach
activities.
Child Health Services (e.g., nutrition, immunization, prevention and management of childhood
infections):
 Assess the client’s exclusive breastfeeding practices.
 Assess the client’s risk of HIV infection to prevent MTCT.
 Assess the client’s fertility desires (spacing, limiting, ending).
 Include dual-protection information during FP assessment and counseling.
 Assess the client’s needs to transition to another method of FP when the criteria for use of
LAM no longer exist or when indicated by the client’s desire.
 Provide FP counseling and methods or referral for FP methods during client encounters for
child health services.
Source: Farrell BL. Family Planning – Integrated HIV Services: A Framework for Integrating Family Planning
and Antiretroviral Therapy Services. New York: EngenderHealth, 2007.
Participant Manual: Contraception for Clients with HIV Curriculum
page 79
FP/HIV Service Integration – Client Contact Opportunities
Instructions: Examine the sample map and read the explanation below and then develop (on a
separate sheet of paper) a map that reflects the client contact opportunities in the community or
facility where you work. The map is an abstract representation (rather than floor plan of the
facility) that depicts a “client’s path” through various health care settings and specific locations
where services are provided at each facility. After completing the map showing points of contact
with a typical client, identify where family planning (or HIV-related messages, depending on the
current focus of the services offered) can be incorporated into a client’s visit. Depending on the
setting, points of contact may include group talks; reception; individual and couple counseling;
history-taking; testing; follow-up appointments; or community outreach as part of PMTCT, VCT,
FP, ART services – any contact with clients.
Consider your current role in interacting with clients at these points of contact and how your role
will change as you begin offering integrated services. Be creative as you develop your map and
consider discussions that you may have had with your supervisor and colleagues about changes
that are occurring as a result of integrating services (e.g., new or reassigned staff, expanded
services, revised job descriptions, or changes in client flow and the location of specific services).
There are a number of opportunities where family planning can be integrated with other
services for clients. In the example depicted above, the client may receive encouragement from
a CBD worker to seek care at the primary health care (PHC) center to confirm her pregnancy
or acquire contraception if not pregnant and desiring to postpone pregnancy. At the PHC
center, the receptionist can provide information about the services offered, and a sign
describing the services can be posted on the wall. The waiting area can include brochures and
posters that describe healthy behaviors, contraceptive options, and other information of interest
to clients. This area may also be a place where providers give group health talks or show
videos about topics of interest.
The antenatal care (ANC) visit gives providers an opportunity to provide information tailored
to the individual’s primary reason for coming to the facility but can also be an opportunity to
query clients about secondary RH issues that may also be of concern to them. Although a
pregnant woman has no need for contraception, she can be considering what contraceptive
method she would like to use after delivery to ensure that her next pregnancy is spaced as
desired. Counseling about this can occur during any ANC visit. Women seeking care for
incomplete abortion should also receive counseling and the method of their choice.
Participant Manual: Contraception for Clients with HIV Curriculum
page 80
For any client interested in family planning, including those with HIV, ensure that the client is
prepared to make a fully informed decision about a contraceptive method (use flip charts and
brochures to share information) and that the client is medically eligible to use her chosen method
(use eligibility checklists). Be sure to note the client’s RH decisions or method choices in the
client’s chart or record – this is especially important for women who plan to initiate a method
immediately postpartum (e.g., LAM, IUD, female sterilization). Clients who are referred for
ARV therapy should be encouraged to share their decisions about contraceptive methods with
their ARV providers.
Labor and delivery generally do not a present a good opportunity for sharing information that is
not directly related to the birth (unless the woman has previously made a decision about
immediate postpartum IUD insertion or female sterilization during a caesarian section).
However, the maternity ward provides an opportunity to counsel a woman about contraceptive
options and to ensure that she leaves the hospital with her method of choice. The six-week
postpartum visit at the PHC center presents another opportunity to reach women with messages
about the importance of contraception for maintaining their health and that of their infants. At
six-weeks postpartum, women can initiate most contraceptive methods (except those that contain
estrogen if they are breastfeeding). A mobile clinic or other community-based program can
provide easy access to contraceptive resupply and ongoing support for contraceptive continuation
and uptake.
Participant Manual: Contraception for Clients with HIV Curriculum
page 81
Sexual Activity, Pregnancy, and Contraception –
Raising the Subject with HIV-positive Clients during Counseling
HIV-positive women and men have the same sexual thoughts, desires, and feelings as
people their own age who do not have HIV. Some have an overwhelming desire to have
children. Many however, are confused, ashamed and afraid of these feelings.
They have heard about the risks of transmitting HIV infection to others, but they still have strong
desires and needs to have sexual relations. They have heard about the importance of disclosing
their HIV status to their partners, but may feel unable to do so. Moreover, they assume that
health providers expect that all people with HIV should avoid sexual relations completely,
regardless of their circumstances, and that they certainly should never get pregnant.
As a result, men and women with HIV are often reluctant to raise issues concerning sexual
activity, pregnancy, and contraception with health providers, even though they want to discuss
these issues. It is therefore important that health providers raise these topics with their HIVpositive clients regardless of their age, marital status, ethnicity,
Informed and volunsex, religion, race, educational level, or sexual orientation.
tary choice is the
foundation of effecTalking about these subjects is challenging for health providers,
tive sexual and
too. Health providers must:
reproductive health
 be knowledgeable of the medical and social issues involved.
counseling. Well acknowledge that they may not but are willing to try to
informed clients,
understand how their clients are thinking and feeling.
who voluntarily
 provide factual, unbiased, and complete information that
make knowledgeable
allow their clients to make free, informed choices.
decisions, from a
 remain non-judgmental while treading the fine line of not
range of possible
options, are more
condoning or re-enforcing behaviors that may put others
likely to be satisfied.
unknowingly at risk of HIV infection.
Not surprisingly, it is often difficult for providers to ask personal, sensitive questions. The
guidelines included on the next few pages may help facilitate these interactions.
Counseling Clients with HIV about Pregnancy
Providers who counsel clients with HIV who are considering pregnancy should explain that
pregnancy does not appear to accelerate HIV progression, even among women not receiving
antiretroviral therapy. Although pregnant women do not need contraception, condom use
should be encouraged to prevent the transmission of HIV and other STIs between partners.
For discordant couples where the male partner is positive, it is also very important to continue
using condoms during pregnancy. Although evidence is inconsistent, one large study
demonstrates that pregnant women may have higher risk of HIV acquisition.
Providers should also emphasize the risk of transmitting HIV from mother to child. Rates of
mother-to-child HIV transmission range from 15 percent to over 40 percent in the absence of
antiretroviral treatment. Providers should advise that ARV treatment around the time of delivery
can substantially reduce HIV transmission risks during childbirth and immediately postpartum.
Other issues the provider should address during counseling include:
• infection with malaria during pregnancy may increase the risk of HIV transmission to the
infant and also lead to miscarriage.
• the fact that artificial feeding or exclusive breastfeeding for the first six months can reduce
postpartum HIV transmission to the child. However, it is important to keep in mind that
while artificial feeding can reduce HIV transmission, it increases the risk of the infant
dying from other infectious diseases, particularly in the first two months of life.
• the implications of rearing a HIV-positive child, including the course of the child’s
infection and likelihood of premature death.
• the need to consider whether family members will be available to raise children if the
mother dies of AIDS, as may happen without treatment.
• where to go for care and treatment during and after pregnancy.
Participant Manual: Contraception for Clients with HIV Curriculum
page 82
Safer Ways to Achieve Pregnancy for Clients with HIV
Even in low-resource settings, there are a number of steps that a discordant couple can
take to avoid HIV acquisition and transmission while trying to achieve pregnancy. When
counseling discordant couples who desire pregnancy, encourage them to:
• Avoid trying to achieve pregnancy if viral load is high; there are two periods when high
viral load is typical – during early HIV infection and among people with AIDS who are
not receiving ARV treatment – although an individual’s viral load can be high at other
times as well.
• Consider artificial insemination in cases where the male partner is not infected.
• In cases where the female partner is not infected, limit unprotected sex to the time during
the woman’s menstrual cycle when she is ovulating and most likely to conceive. It is
also very important to continue using condoms after conception to avoid contracting
HIV during the time the woman is pregnant and breastfeeding. This is because when a
person is newly infected with HIV, the viral load is very high and the risk of transmitting
HIV is increased. Therefore, if a woman acquires HIV while pregnant or breastfeeding,
the likelihood of transmitting HIV infection to the infant is greater.
Counseling Clients with HIV about Contraception
When counseling women with HIV about their contraceptive options, providers should
consider the client’s medical eligibility for particular contraceptive methods and:
• Provide an overview of method characteristics, including possible side effects and
complications of available contraceptive methods.
• Discuss the effectiveness of available contraceptive methods and how effectiveness
may be affected by a client’s ability to use a method correctly, such as remembering to
take a pill daily. Because unintended pregnancy often presents greater challenges for
women with HIV, they may want to choose a client-independent method.
• Help women who plan to use hormonal contraception consider the implications of
possible interactions between contraceptive hormones and ARV drugs. For women
taking particular ARV drugs, these interactions include the potential for reduced
contraceptive effectiveness or increased hormonal side effects. Also, make sure that
women with HIV who are planning to use oral contraceptives are not taking the
antituberculosis antibiotics, rifampicin or rifabutin. Coinfection with tuberculosis is
common among patients with HIV, and these antibiotics speed up the metabolism of
contraceptive hormones, reducing the effectiveness of oral contraceptives.
• Discuss the limitations of methods to prevent pregnancy and STI/HIV transmission,
emphasizing that methods that are most effective in preventing pregnancy do not offer
protection from HIV and other STIs.
• Emphasize the advantages of dual protection, including dual method use particularly
for discordant couples and for those with multiple partners. When a client chooses one
of the more effective methods for pregnancy prevention, encourage the client to also
use condoms to prevent STI/HIV transmission.
• Help a client consider her partner’s willingness to use condoms, discuss possible
condom negotiation strategies, and offer couples’ counseling.
• Ensure that women know when to return for regular follow-up; if they have questions,
concerns, or problems with the method, and if they need resupply. In the event that a
client’s chosen method cannot be provided on-site, refer the client to a facility where the
method is offered.
Participant Manual: Contraception for Clients with HIV Curriculum
page 83
Counseling about ARVs and Hormonal Contraception
The issues that should be addressed when a woman on ARV treatment plans to use
hormonal contraception include:
• The ability to take oral contraceptive pills correctly. Because some ARV drugs
decrease blood concentration of contraceptive hormones, the risk of contraceptive
failure may be greater if a woman forgets to take pills.
• The need to come back for the next NET-EN injection on time. Although the next
injection usually can be given as much as two weeks late, in the presence of ARV
therapy it is safer to follow a strict injection schedule.
• Willingness to use condoms to ensure additional protection from pregnancy because the
effectiveness of hormonal contraceptives – other than DMPA which provides a wide
margin of effectiveness in each dose – may be compromised by ARV therapy. Focusing
on the pregnancy prevention role of condoms may help when negotiating condom use
with a partner.
Additional Counseling Topics for Clients with HIV
During counseling a provider should explore whether a client knows his or her partner’s
HIV status. When a partner’s HIV status is unknown, a provider should encourage clients
to bring their partners for counseling and testing or provide referrals. Knowing a partner’s
HIV status is important when making decisions about whether to have a child, what
contraceptive methods to use, and how best to prevent STI/HIV transmission. Health
implications and prevention strategies should be discussed for situations when either one
or both partners has HIV infection.
A provider should also discuss whether the client has disclosed her HIV status to her
partner or family. If a woman’s status is undisclosed, counselors should help her determine
whether disclosure of HIV status or use of contraceptives would pose a risk of
abandonment, violence, or loss of financial support for herself and her children.
Depending on the individual situation and needs of the client, the provider should be able
to offer referrals to other reproductive health services if they are not provided on-site.
These services may include STI management and treatment; postpartum, postabortion, and
antenatal care; and HIV care and treatment services, including ARV therapy and
prophylaxis.
Providers should also discuss what family, community, social, legal, nutritional, and child
health supports are available to clients. If clients are interested in these services, discuss
how to access them and provide written referrals if needed.
Participant Manual: Contraception for Clients with HIV Curriculum
page 84
Client-centered Counseling Framework
BEGINNING STAGE: Introductions and Exploration
1. Welcome the client and introduce yourself.
2. Help the client to relax and feel comfortable, assure privacy and confidentiality, and
inform the client about what will be happening during the session.
3. Make general inquiries of the client – primary and secondary reason(s) for coming to
the facility, marital status, children, and home life.
4. Explore the client’s reproductive health goals, needs and concerns, fertility intentions,
sexual life, relevant medical history, social context, and circumstances.
5. Assist the client in determining his or her own risk for STI/HIV acquisition or
transmission, unintended pregnancy, or other reproductive health-related liabilities, as
indicated.
6. Determine existing knowledge and experience about the concerns raised by the client.
MIDDLE STAGE: Discussing Options and Making an Informed Decision
1.
2.
3.
4.
Identify the RH decisions that the client needs to make.
Provide information to facilitate informed decision-making related to the client’s concerns.
Discuss options related to the client’s decision.
Assist the client to make realistic decisions, including determining medical eligibility
for the method of choice if contraception is desired.
5. Help the client to anticipate the potential outcomes of her or his decisions.
END STAGE: Confirm Decision, Build Skills, Take Action
1. Confirm the client’s decision and ensure understanding of its implications.
2. Develop communication and negotiation skills for interacting with partner(s) and other
family members.
3. Develop skills to support the client’s decision and provide memory aids as appropriate.
4. Develop a plan for carrying out decisions.
5. Refer as required to other health or community support services.
GATHER
G – greet
A – ask
T – tell
H – help
E – explain
R – return
The Client-centered
Reproductive Health
Counseling Framework
described above has features
similar to other counseling
frameworks shown here.
REDI
R – rapport-building
E – exploration
D – decision making
I – implementing
Five As
A – assess
A – advise
A – agree
A – assist
A – arrange
Participant Manual: Contraception for Clients with HIV Curriculum
Balanced Model
Greet
Diagnose needs
Discuss/choose
Screen
Give information
Verify comprehension
Ensure follow-up
page 85
What to Say and Do during the Various Stages of Counseling
Note: This is not a checklist – it is a guide to help you remember what actions you want to
accomplish and what information you may want to elicit from clients during the various counseling
stages. The questions that you ask during a counseling session will depend on the interests of the
client and should be part of a relaxed, two-way exchange. Examples of possible statements and
questions to facilitate exploration of a client’s sexual and RH concerns are included in italics.
Practice using these examples during counseling sessions; it may help relieve the anxiety that you
experience when attempting to formulate appropriate questions about sensitive issues. You may
prefer to make notes during interactions with clients so that you can be sure to address all of the
concerns the client raises.
BEGINNING STAGE: Introductions and Exploration
1. Welcome the client and introduce yourself.
–
–
–
Be polite and cordial during the initial contact; it can help establish a good rapport for the
entire interaction.
Greet the client in a culturally appropriate and respectful manner.
Tell the client your name and your role at the facility.
Welcome to the ________ Clinic. We are very happy to serve you today.
My name is Nurse________ and I am your health care provider.
What is your name? I am pleased to meet you, Mrs.__________.
Mrs._______, please come with me and I will show you to the
consultation room.
2. Help the client to relax and feel comfortable, assure privacy and confidentiality, and
inform the client about what will be happening during the session.
–
–
–
–
Be sure that the client is physically comfortable (e.g., seated in a chair near the provider so
that eye contact and information sharing are facilitated).
Talk to the client about sensitive issues only in a private space where the conversation
cannot be overheard.
Reassure the client that everything she or he talks about will be kept confidential and
private.
Provide a general overview of the goals of the session and what the session will be like.
Please have a seat here. Are you comfortable? Before we get started, I
just want to assure you that anything we discuss will be confidential.
The information that you share becomes part of your medical record
and will only be available to other health care workers directly
involved in your care and treatment on an as-needed basis – unless
you give permission to discuss your concerns or conditions with
someone else, such as your husband or partner, during couple
counseling. I want to do all I can to help you during our time together.
What we discuss and do is up to you – I will ask you some questions to
help us get started, but ultimately we want to make sure your needs
are met. Initially, we will explore your needs and concerns and
identify what you would like to accomplish, then we will look at your
options and figure out how best to help you meet your goals. How
does that sound to you?
3. Make general inquiries of the client (e.g., primary and secondary reason(s) for coming
to the facility, marital status, children, and home life).
–
Identify the reason for the client’s visit.
Mrs. ________, please tell me why you came to the clinic – what
can I help you with today?
Participant Manual: Contraception for Clients with HIV Curriculum
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–
Ask general questions such as age, partner’s name, number of children.
Very good – I’m sure that I can assist you with <restate reason(s) for
coming>. But first let me learn a little more about you so that I can
respond appropriately to your needs. How old are you? Please tell
me about your family. Do you have any children – what are their
ages? Tell me about your partner/spouse. How are you feeling
today?
–
Reassure the client that she or he should feel comfortable discussing any sexual and
reproductive health concerns.
I know that sexual and reproductive health issues are of concern to
many of my clients, and they often do not know with whom they can
talk about them. I want you to feel comfortable telling or asking me
whatever is on your mind so that I can help you as much as
possible.
–
Explain to the client that there are some standard questions that you ask all clients. Assure
the client that the questions are routine and that everyone is asked the same questions.
I am going to ask you some personal questions now. I ask these
questions of all my clients, because for me to help you, I need to
fully understand your situation.
–
Reassure the client that the questions will have a direct bearing on the client’s health care
and the decisions made during the visit. Let the client know that this information is very
important because it helps you determine how to help the client to think about his or her
concerns. Talk to the client about the importance of being honest and reassure the client
that you are not there to judge.
It is important for me to ask you these questions so that I can help
you to make decisions that are right for you. It is important that you
answer the questions honestly so that we can discuss the issues fully.
Do not worry about what I might think; I am not here to judge you.
Remember, anything we discuss today will be completely confidential
and private.
–
Acknowledge that these are sensitive issues and that some questions may be asking for
more information than a client feels like sharing.
If there are any particular questions you do not feel comfortable
answering, please let me know.
–
If a client is unwilling for any reason to discuss a particular issue, you could speak about
the issue hypothetically or use other anonymous clients as examples.
I know women who are HIV-positive who have not yet disclosed their
HIV status to their husbands and who continue to have sexual intercourse
without using condoms. When they tell me this, I advise them to …
–
If a client reveals that she or he (or a partner) has HIV, explain that having HIV does not
stop one from having thoughts and desires about sex, or that one stops thinking about
having children. Explain that you understand that many people with HIV continue to have
sexual relations and that you support the right to plan lives and families as the client
desires.
Being HIV-positive does not stop you from having exactly the
same sexual feelings, desires, and thoughts about having
children as other men and women of your age. I will support
your rights to achieve your reproductive health goals in
whatever way I can.
Participant Manual: Contraception for Clients with HIV Curriculum
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4. Explore the client’s reproductive health goals, needs and concerns, fertility intentions,
sexual life, relevant medical history, social context, and circumstances.

Explore the client’s reproductive health goals, pregnancy history, fertility intentions, and
knowledge of and use of family planning methods, including condoms. Investigate interest
in short-term, long-term, or permanent contraception.
Earlier you mentioned that you and your husband have ____
children, is that your ideal family? How would you describe your
ideal family? Would you like to have a child/more children?
Do you think that you might change your mind about having a
child? What factors might make you change your mind?
Are you hoping to get pregnant soon or would you like to delay
pregnancy? How do you feel about (another) pregnancy at this
time? How does your partner feel?
Are there any questions or concerns about pregnancy that you
would like to discuss? If you are hoping to become pregnant, what
concerns do you have about being pregnant or trying to conceive?
If you are hoping to delay pregnancy, have you thought about using
a contraceptive method? Have you used a method(s) previously?
Are you using a method now?
If you are hoping to start a method, do you have a method in mind?
If you do not have a method in mind, the answers to these questions
can help you narrow down the available options:
Do you wish to have children in the future?
Are you breastfeeding an infant less than six months old?
Do you have the cooperation of your partner in family planning?
Are there any methods that you do not want to use or have not
tolerated in the past?
Do you need a method that provides protection from STIs/HIV?
How do you and your partner(s) feel about using condoms?
Have you used condoms? How often do you and your partner(s) use
condoms?
Have you talked with your partner(s) about using condoms? How
did he or she respond?
Have you had any problems with using condoms? What problems?
What did you do about them?
Do you have any questions or concerns about using condoms that
you would like to discuss?

Explore the context of the client’s sexual relationships.
– Ask about the client’s sexual relationship(s), what is the nature of the relationship(s)
(including any violence or abuse), and how do they feel about it.
Are you currently in, or are you thinking about starting, a sexual
relationship?
Can you tell me how you feel about your current sexual
relationship?
Although you may not currently be involved in a sexual relationship,
how do you feel about having one? Do you think that you might
change your mind about having a sexual relationship in the future?
What might make you change your mind?
Do you have any questions or concerns that you would like to
discuss about your sexual relationship with your partner(s)?
What concerns do you have? Does your partner treat you the way
you would like to be treated? What would you like to be different?
Participant Manual: Contraception for Clients with HIV Curriculum
page 88
–
Determine a client’s ability to communicate with partners about sexual activity, family
planning, HIV and STIs.
How do you feel about your ability to communicate with your partner
about sexual activity? – using contraceptives? – using condoms?
– seeking treatment for STIs? – disclosing HIV status?
Do you have any questions or concerns about telling people (e.g., family
friends, partners) that you are HIV-positive that you would like to discuss?
What do you think would help you to feel more comfortable
communicating with your partner?
–
Discuss the client’s knowledge of the partner’s sexual behavior outside of the
relationship.
Do you think that your partner may have other partners as well as
you? Why do you think that?
–
Inquire about sexual practices and safe sex.
(Note: A client will often provide a nonspecific response to these queries. However, it
is important to be specific about what “sex” or “intercourse” means to the client, as it
is essential for determining individual risk. Find out if sex is vaginal or anal, as well as
whether the client has performed or received oral sex.)
What kinds of sexual practices do you and your partner(s) do
together? How do you have sex?
How many partners do you have now? How many in the past?
How often do you engage in unprotected intercourse?
Have you heard about safe sex? What does safe sex mean to you?
If you avoid having sex, how do you feel about that? How does
avoiding sex affect your relationship(s) with other people?
–
Inquire about the client’s sexual pleasure and problems.
How would you describe your satisfaction with your sex life?
What sexual problems do you or your partner have?

Explore the client’s and partner’s STI history, present symptoms, and HIV status.
Have you ever been diagnosed with or treated for a sexually
transmitted disease? Do you, or have ever you had, an unusual
discharge from your (penis/vagina)? Do you currently feel any
itching, burning, or other discomfort?
Have you ever had an HIV test? If yes, when was the last time that
you had an HIV test? What was the result of your HIV test?
What care or treatment, if any, are you currently receiving or taking
for HIV? What treatment, if any, are you taking for other infections,
for example, tuberculosis?
Have you told anyone else that you are HIV-positive? Whom have
you told? How did it go when you told the person? How did the
person react?
Have you told your sexual partner that you are HIV-positive? How
did it go when you told your partner? How did your partner react?
How do you feel about not telling your partner? How is not
revealing your status affecting your relationship?

Explore the client’s overall health.
How is your health in general? Please describe any recent illness or
chronic problems. As indicated, probe for: date of last menstrual
period and characteristics of the bleeding cycle, smoking or other
harmful behaviors, breastfeeding, current or previous illnesses
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(e.g., STIs, HIV, TB, cancers, diabetes, hypertension, pain during
intercourse, difficulties during pregnancy or delivery, surgeries),
possible exposure and current symptoms (e.g., discharges, abnormal
bleeding, feeling tired, fever, headaches), relevant test results,
current medications, and nutritional status. As indicated, also probe
for the partner’s pertinent history and symptoms.

Explore the client’s current living and family situation (e.g., number of children living at
home, extended family, social networks, sources of support in family and community).
Please tell me about your situation at home. How many people live
in the house? Do you have enough help with childcare and
household chores? Whom can you call for help if you need it?
Do you have friends in the community to talk with about personal
and family problems?

Explore other factors about the client’s circumstances that may limit her power to make
decisions (e.g., financial dependence on partner(s), tensions within an extended family,
fear of violence).
Do you have sufficient money to do the things that you need to do,
such as provide food, medicine, and school fees? Can you describe
what happens when there are not sufficient funds to cover the
household’s expenses? Can you describe how you resolve
disagreements with your spouse, partner, or other relatives?

Explore the client’s current work situation.
Please describe how you feel about work. Do you find the work satisfying,
challenging, or stressful? Do you feel fairly compensated for your
efforts? Do you get along well with your supervisor and colleagues?
Does your work schedule accommodate your other commitments?
5. Assist the client in determining his or her risk for STI/HIV acquisition or transmission,
unintended pregnancy, or other reproductive health-related liabilities, as indicated.
Given what we discussed about your partner(s), the sexual activities
that you engage in, and your history of sexually transmitted
infections – what do you feel is your level of individual risk for
STI/HIV infection? – unintended pregnancy?
There are some other factors that can also contribute to your
individual risk of acquiring HIV infection, including drug and
alcohol abuse and exposure to contaminated blood during invasive
procedures (e.g., traditional circumcision). Are any of these concerns
relevant in your situation?
What concerns do you have about transmission of STI/HIV to your
partner during intercourse? – fetus during pregnancy or delivery?
– or infant during breastfeeding?
Given your level of risk, would you like to consider some options to
lower it, or do you find the risk acceptable?
6. Determine existing knowledge and experience about the issues and concerns raised by the
client.
What do you think you can do to lower your risk for STI/HIV infection?
– unintended pregnancy?
What do you know about dual protection? – safer sex and using
condoms? – infant feeding? – proper nutrition during pregnancy?
– compliance with ARV therapy?
What topics do you want to learn more about?
Adapted from Sexuality and Sexual Health: On-line Mini-course. New York: EngenderHealth, 2001.
Participant Manual: Contraception for Clients with HIV Curriculum
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MIDDLE STAGE: Discussing Options and Making an Informed Decision
1. Identify the RH decisions that the client needs to make.
–
–
–
Review the issues and concerns raised by the client during the beginning stage.
Confirm which issues and concerns the client would like to focus on during this session.
Explain the importance of the client making her or his own decisions.
2. Provide information to facilitate informed decision-making related to the client’s
concerns (e.g., STI/HIV transmission and prevention of infection or re-infection,
achieving or preventing pregnancy, recommendations for antenatal and postpartum
care, dual protection, other topics relevant to the client’s issues).
–
–
–
–
Explain health risks and benefits relevant to the client’s personal circumstances (e.g.,
STI/HIV infection or reinfection risks, pregnancy risks).
For clients making a decision regarding a contraceptive method, provide a brief overview
of the contraceptive options that match the client’s stated desires.
Discuss the importance of condoms as the only method that protects against both
pregnancy and STI/HIV infection or reinfection.
For clients wanting to achieve pregnancy, explain how to achieve pregnancy while
reducing risk to the uninfected partner; explain infant feeding options and MTCT risk; and
discuss options for healthy living and other concerns expressed by the client.
3. Discuss options related to the client’s decision (e.g., appropriate methods to achieve or prevent
pregnancy, alternatives for achieving dual protection, strategies for preventing STIs/HIV,
ARV therapy requirements, infant feeding options, other client interests).
–
–
–
Make sure that the discussion centers on options that are appropriate to the client’s
individual needs and desires.
Ensure that the relevant options are presented in an unbiased manner (e.g., pros and cons
of a pregnancy, benefits and side effects of ARV therapy, breastfeeding versus alterative
feeding, benefits and anxieties of knowing HIV status).
For clients making a decision regarding a contraceptive method, focus on the method of
interest to the client and provide more detailed information on how to use the method,
potential side effects, the method’s potential impact on sexual relations, and possible need
for STI/HIV protection.
4. Assist the client to make realistic decisions, including determining medical eligibility
for the method of choice if contraception is desired.
–
–
Help the client to assess whether her or his decisions are feasible given her or his
relationship(s), family life, economic situation, and medical history (e.g., using medical
eligibility screening checklist for client’s method of choice).
Brainstorm with the client about overcoming potential barriers to her or his decisions.
5. Help the client to anticipate the potential outcomes of her or his decisions.
–
–
–
–
–
Assist the client to identify the possible outcomes (positive or negative) of the actions that
she or he chooses to take.
Explore with the client how a partner(s) or family member(s) may react to the actions
being considered (e.g., suggesting condom use, discussing sexuality, revealing HIV
status).
Help the client to determine the incremental steps that can be taken over time to improve
the likelihood of carrying the decision to completion.
Help the client to consider other options when the client is unable to talk with a partner(s)
(e.g., indirect communication or avoiding risky situations).
Discuss the local community resources that are available to support the client (e.g., PLWA
groups, mothers’ groups).
Participant Manual: Contraception for Clients with HIV Curriculum
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END STAGE: Confirm Decision, Build Skills, Take Action
1. Confirm the client’s decision and ensure understanding of its implications.
–
–
Confirm decision(s) the client made and reiterate the implications of the decision (i.e.,
acceptability of side effects, willingness to deal with partner reaction).
Encourage the client to reflect on the decision by talking about what the decision means to
her or him and describing any necessary behavior changes or reservations in her or his own
words.
2. Develop communication and negotiation skills for interacting with partner(s) and other
family members. Refer to the Counseling Tool, page 46 for additional guidance.
–
–
–
Discuss the client’s concerns about talking with partner(s) and family members about
sensitive issues and offer ideas for improving communication and negotiation.
Teach negotiation skills and discuss ways to make the client’s decision more appealing and
easy to implement. For example, if a client finds it difficult to ask a partner to use condoms
for STI/HIV prevention, discuss whether it might be easier to talk about condoms as a
family planning method.
Role-play with the client possible situations that may occur up when talking about
sensitive issues with a partner or family member.
3. Develop skills to support the client’s decision and provide memory aids as appropriate
(e.g., using condoms, contraceptive methods, ARV drugs; infant feeding techniques;
ensuring safe pregnancy and delivery; and other issues related to the client’s decision).
–
–
–
–
Ensure that the client has the basic knowledge to implement the decision. Confirm
understanding by asking the client to describe the key messages, steps, or instructions for
use and clarify questions raised by the client.
If the client will be using condoms, demonstrate correct male or female condom use on
penis and vagina models. Ask the client to repeat the demonstration to be sure that the
client understands. Provide condoms to the client and make sure the client knows where
and how to obtain more.
If the client has selected a contraceptive method, ensure the client understands how to use
the method by repeating basic information, including when to return to the clinic for
resupply or problems.
Provide the client with a brochure that includes written and illustrative “how to”
information to reinforce new knowledge and skills.
4. Develop a plan for carrying out decisions.
–
–
–
Develop a step-by-step plan of action for the decision (e.g., obtain condoms and/or another
family planning method today, talk with your partner about the decision tonight after the
children are asleep, begin taking COCs every night at dinner, use condoms during sex, and
obtain ARV drugs at pharmacy and follow therapy regimen).
Identify social supports or barriers and what the client can do to use or overcome them.
Invite the client back for a follow-up visit to provide ongoing support and encouragement.
5. Refer as required to other health and community support services.
–
–
Encourage the client to seek assistance from specialized support services – for concerns
addressed during the session and any that were identified but not addressed.
Provide a written referral and information on these services as needed.
Participant Manual: Contraception for Clients with HIV Curriculum
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Training Resource 10.5. Counseling Observation Checklist
Case: ____________________________ Provider: _______________________________ Client: _______________________________ Observer: _______________________________ Date: ___________________________
Overall
Establishes and maintains rapport ..........................................................
Yes
No
N/A
Facilitate Informed Decision-making and Problem-solving
Facilitates analysis of options in context of client’s situation ..................
Shows respect and is nonjudgmental .....................................................
Determines if medically eligible or appropriate .......................................
Uses simple, clear language ...................................................................
Reaches agreement on decision or plan in collaboration with client ........
Actively listens to client ........................................................................
Attends to client’s emotional needs .......................................................
Encourages client participation ..............................................................
Explains what will occur during session or procedure ...........................
Ensures client understanding and corrects misunderstandings ...............
Uses appropriate nonverbal communication (body language) ...............
Ensures confidentiality and privacy .......................................................
Offers to involve client’s partner (as appropriate) .................................
Uses job aids appropriately (if available) ...............................................
Yes
No
N/A
Provide Assistance to Support Client’s Decision
Helps to plan, rehearse, carry out decision ...............................................
Provides contraceptive method and instructions on correct use ...............
Reinforces correct use, including when to return .....................................
Gives instructions and demonstrates correct condom use ........................
Corrects and reinforces demonstration of condom use by client ..............
Gives condoms .........................................................................................
Gives treatment, supplies, medications (as indicated) ..............................
Ensures comprehension of facts and implications ....................................
Assess Client’s Needs and Concerns
Asks about reason for visit .....................................................................
Asks about client’s partner(s), children, family relationships ................
Arranges follow-up visit for supplies, health check, etc. ..........................
Offers referral to support group (if applicable) ........................................
Arranges referral to outside services (for client or partner as applicable) .......
Reviews RH goals and concerns (fertility intentions, FP, STIs).................
Explores sexual behavior and risks, sexuality, physical changes ...........
Case-Specific Observations or Questions:
Queries pregnancy status and other pertinent medical history ...............
................................................................................................................................
................................................................................................................................
................................................................................................................................
................................................................................................................................
................................................................................................................................
................................................................................................................................
................................................................................................................................
................................................................................................................................
Identifies areas to evaluate during physical exam (if indicated) ............
Provide Information and Options Related to Client’s Concerns
Advises on safer sex, STI and HIV prevention ......................................
Advises on achieving desired pregnancy as safely as possible ..............
Advises on use of contraceptive methods and preventing pregnancy ....
Advises on client’s other identified issues or concerns ..........................
Participant Manual: Contraception for Clients with HIV Curriculum
page 93
SESSION 11: Creating and Maintaining a Safe and
Efficient Work Environment
Standard Precautions in Health Care Settings
The following is a summary of standard precautions for health care and home settings,
offering a broad set of recommendations to help minimize the risk of exposure to
infectious material, such as blood and other body fluids. Standard precautions help break
the disease transmission cycle at the “mode of transmission” step and decrease the risk of
infection for both clients and health care workers.
Handwashing
Wash your hands with soap and running water after contact with blood, body fluids,
secretions, excretions, and contaminated items, whether you have worn gloves or not.
Wash hands immediately after gloves have been removed and between client contacts to
avoid transferring microorganisms among clients as well as to the environment.
Gloves
Wear gloves when coming in contact with blood, body fluids, secretions, excretions, or
contaminated items. Put on clean gloves just before touching mucous membranes and nonintact skin. Change into a new, clean pair of gloves between tasks and procedures on the
same client after contact with material that may contain a high concentration of
microorganisms. Rinse gloved hands in 0.5 percent chlorine solution before removing
gloves. Then remove gloves immediately before touching uncontaminated items and
surfaces. Note: Health care staff with open lesions, cuts, weeping dermatitis, rashes, or
severely chapped hands should avoid direct client contact and should not handle
contaminated equipment because breaks in the skin provide points for microorganisms to
enter the bloodstream and cause infection.
Eye Protection
Wear eye protection and a mask, or a face shield, to protect mucous membranes of the
eyes, nose, and mouth during procedures (e.g., during delivery or cutting of the umbilical
cord) and client-care activities that might produce splashes or sprays of blood, body fluids,
secretions, and excretions.
Protective Clothing
Wear clean, non-sterile gowns to protect the skin and prevent the soiling of clothing
during procedures and client-care activities that might produce splashes or sprays of blood,
body fluids, secretions, or excretions. If feasible, use a plastic or rubber barrier (e.g.,
apron) to protect clothing if large amounts of soiling are anticipated (e.g., during delivery).
Remove a soiled gown immediately, place it in a designated container for
decontamination, and wash hands.
Instrument Processing
Process used instruments consistent with accepted infection-prevention guidelines for
decontamination, cleaning, high-level disinfection, or sterilization. Make sure that a
reusable instrument is not used on another client until it has been appropriately processed.
Handling Sharps
Handle sharps with care to avoid injury and reduce the risk of infection.

Avoid recapping needles (use the one-hand capping technique if recapping is
absolutely necessary).

Do not bend, break, or cut needles after use.

Do not remove the needle from the syringe before disposal.
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Dispose of used sharps in a puncture-resistant container that is not overly full
immediately after use.

Wear utility gloves when disposing of sharps containers.
If injured by a contaminated needle or sharp instrument, wash the area immediately with
soap and water and follow your facility’s postexposure prophylaxis guidelines.

Environmental Cleanliness and Waste Disposal
Maintain environmental cleanliness and waste-disposal practices according to appropriate
infection-prevention guidelines. Make sure that liquid waste is placed in a container with
enough disinfecting solution to effectively kill organisms. Make sure that all contaminated
waste (bloody dressings, swabs, tissues, gauze, cloths soiled with body fluids) is placed in
designated and clearly marked bags or containers, collected, and taken for incineration or
other safe disposal. Immediately clean surface spills of blood, body fluids, secretions, and
excretions with a disinfectant solution such as 0.5 percent chlorine solution. Then clean
the area with detergent and water.
Handling and Processing Linen
When handling linen soiled by blood, body fluids, secretions, or excretions, always wear
gloves and place linen in designated and clearly marked bags or containers. If using a
plastic bag, place linen in one bag and then place that bag inside another plastic bag
(double bag). Transport soiled linen in a way that avoids puncturing the bag or losing
soiled items on the way to the laundry. Launder soiled linen using detergent and germicide
according to appropriate infection-prevention guidelines.
Preventing Needlestick and Sharp-Instrument Injuries
In most countries, exact data are not available on the number of needlestick and sharp
instrument injuries experienced by health care workers each year. Most reported needlestick
injuries involve nurses, but midwives, laboratory staff, physicians, housekeepers, and other
health care workers are also injured, resulting in exposure to bloodborne organisms (e.g.,
hepatitis B and C viruses, or HIV). The emotional and physical impact is serious, whether or
not infection is transmitted. It is far simpler and more cost-effective to prevent injuries from
sharp instruments than it is to manage the emotional and financial costs of trauma to the
worker and her or his partner, such as extensive counseling, drugs (if available), and followup monitoring. Injuries by sharp instruments can be prevented. To better understand how to
prevent these injuries, it is important to understand how they occur.
How Injuries with Needles and Other Sharps Commonly Occur
Injuries by needles and sharp instruments occur in many circumstances including when:

Suture needles or other items are manipulated by hand (e.g., when a suture needle is
repositioned in a needle holder or a scalpel is mounted on a scalpel holder)

Instruments are dismantled after use

Needles or sharps are placed into disposal containers that are full or do not allow for
easy insertion of the item

Needles are removed from IV tubing ports

Needles are recapped, bent, cut, or broken after use

Blood is transferred from a syringe into a test tube

Fingers are used as a guide by surgeons or surgical assistants

Tissue is hand-held during suturing or sutures are tied with the needle still attached

Needles are left exposed on needle holders

A scalpel or other sharp instrument is handed from the user to an assistant or from the
assistant to the user
Participant Manual: Contraception for Clients with HIV Curriculum
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Injury-Prevention Strategies
There are many strategies that can be used to reduce the risk of injury during health care
services.
Needles

Let the client know when you are going to give an injection to avoid startling the client
and causing an injury.

Avoid capping needles after use. Use the one-hand capping method if recapping is
absolutely necessary. Do not bend, break, cut, or remove needles from syringes after use.

Dispose of used needles immediately in a puncture-resistant container.

Place sharps disposal containers close to work areas so that staff do not have to cross
the room or leave the area to find one.

Burn or bury the container when it is three-quarters full.

When transferring blood from a syringe into a test tube, place the test tube in a holder
and insert the needle into the test tube using one hand.

Promote safety awareness during in-service trainings, focusing on behavior change to
prevent or minimize needlestick and sharp-instrument injuries.
Scalpels and Other Sharps

Manipulate or reposition scalpel blades and suture needles using forceps rather than
your fingers to grasp the blade or needle.

Consider using staples rather than sutures and suture needles, if it would be an
appropriate option.

Use curved needles with a needle holder as a safer option to straight, hand-held needles.

Blunt instruments, such as rounded-point scissors, non-penetrating towel clips, blunt
retractors, and synthetic sutures instead of wire sutures, can be an alternative for
preventing injuries.

When transferring sharps between personnel, avoid hand-to-hand transfer. Create a
safety zone using a flat tray, mat, part of the instrument stand, or designated area on the
field where the user can place instruments and the assistant can safely pick them up. Do
not use a kidney basin, because it can be hard to pick up items from inside the basin.
Team Efforts for Prevention of Injuries

When moving, communicate verbally with those around you to prevent collisions
between hand or body and sharps.

During surgical procedures, announce the transfer of sharps to avoid injury. For
example, always say “needle back” or “sharp back” when passing these instruments to
the safety zone.

Avoid reflex sponging of tissue unanticipated by the surgeon when a sharp is in use.

Keep hands away from the incision during cutting and suturing.

Avoid manual retraction; use retractors whenever possible.

Maintain a well-lit surgical field to facilitate visibility of sharp items and instruments.

Keep an eye on all sharps in use until they are returned to the safety zone and removed
from the field. Meet as a team to analyze patterns of injury and to develop strategies
for their prevention.
Keep in mind that along with protecting providers and clients, injury-prevention strategies
protect housekeeping, maintenance, and other staff working in health care facilities.
Source: Reducing Stigma and Discrimination Related to HIV and AIDS, Participant’s Handbook. New York:
EngenderHealth, 2004. For more detailed information about infection prevention practices, refer to: Infection Prevention:
A Reference Booklet for Health Care Providers. New York: EngenderHealth, 2001.
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Postexposure Care and Prophylaxis for Injured Health Care Staff
The risk of becoming infected with HIV following a needlestick or sharp-instrument injury when
the source is known to be infected with HIV averages 1 in 300. Most injuries do not result in
infection. The risk of becoming infected with HIV after mucous membrane or non-intact skin has
been exposed is about 1 in 1,000.
The risk of infection with HIV after an occupational exposure is related to:
• The amount of blood on the needle or device
• The depth of the injury
• Whether the needle or device was placed directly in a patient’s artery or vein
• The infectious status of the source person
Following an injury with a contaminated needle or sharp instrument, or a mucous membrane
exposure, immediate action should be taken to reduce the risk of infection.
Estimated Risk of HIV Transmission
Following Different Types of Exposure
Type of Exposure
Estimated Risk
Needlestick or sharpinstrument injury
0.3%
Mucous membrane or nonintact skin
0.1%
Needle-sharing exposure with
an infected source
0.67%
Receptive anal intercourse
with an infected source
0.5 – 3.0%
Receptive vaginal intercourse
with an infected source
0.1%
Insertive anal intercourse with
an infected source
0.065%
Insertive vaginal intercourse
with an infected source
0.05%
Oral sex with ejaculation with
an infected source
<0.05%
Conflicting data; risk is considered
extremely low
Bell DM. Occupational risk of human immunodeficiency virus infection in
healthcare workers: an overview. Am J Med 1997;102(5B):9-15.
Mayer KH, Anderson DJ. Heterosexual HIV transmission. Infect Agents Dis
1995;4:273-84.
WHO, UNAIDS, and the U.S. Centers
for Disease Control and Prevention
recommend postexposure prophylaxis
(PEP) for health care workers exposed
to blood and other body fluids that may
be contaminated with HIV – where
antiretroviral drugs are available – if it
is determined that the risk of infection
is significant. Treatment is not
recommended after every occupational
exposure because most exposures do
not result in infection and the side
effects of the treatment may be serious.
Postexposure care should be guided by
local policies and is dependent on the
availability of counseling, HIV testing,
and ARV drugs. But generally, taking a
triple ARV drug regimen significantly
lowers the risk of acquiring infection.
However, health care workers have
become HIV-positive following
occupational exposure even though
they received postexposure
prophylaxis.
1. Immediately following possible exposure:

Flush the injured area with running water and wash with soap and water. There is no
evidence that squeezing the wound decreases the risk of transmitting bloodborne
organisms.

If a mucous membrane has been injured or splashed – such as the eyes, nose, or
mouth – flush with a large amount of clean water, saline, or sterile irrigation
solution. Also, remove any clothing or other items that may have been contaminated.

In the absence of water, an antiseptic solution can be used to flush the area (with
the exception of the eyes, nose, and mouth), although antiseptic solutions have not
been proven to be any more effective than soap and water. Do not apply any
caustic agents (e.g., bleach) because it may cause inflammation and potentially
facilitate the entry of HIV.
Participant Manual: Contraception for Clients with HIV Curriculum
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2. Assess the injured health worker’s risk for infection following exposure.
If feasible, determine the HIV status of the source patient following appropriate
counseling and informed consent (see Testing the Source Patient and Related Issues,
next page). This is particularly important in settings with limited resources, where
antiretroviral drugs may not be readily available. Determining that the source patient is
HIV-negative will eliminate the need for drug therapy, its attendant side effects, and
costs, and the emotional stress of not knowing either the risk posed by the exposure or
whether the drug therapy will work.
The risk of infection following occupational exposure is increased when:

The needle or instrument is visibly contaminated with blood

The needle was used directly in an artery or vein before the injury occurred

The injury is deep

The source patient has very advanced AIDS
3. If, following counseling, the injured worker decides to undergo postexposure
prophylaxis:

Draw blood for a baseline HIV-antibody test as soon as possible.

Start multi-drug treatment as soon as possible, within one to two hours or at most
24 hours after the injury, and continue for four weeks from the day of exposure.

Review possible side effects associated with the drugs.

Instruct the health care worker to report sudden or severe flu-like symptoms,
including fever, rash, muscle aches, tiredness, malaise, or swollen glands, as they
may indicate HIV infection, drug reaction, or other medical conditions.

Give information about behaviors to prevent transmission of HIV, such as not
donating blood, semen, organs, or tissue and practicing safer sex. Also, in settings
where breast milk substitutes are affordable and accessible, and can be used safely,
nursing women may be advised to avoid breastfeeding until their status is known.

Provide counseling to address the injured worker’s emotional response, fears, and
concerns about the reactions of her or his partner or spouse.
4. Follow-up care for those undergoing postexposure prophylaxis should include:

Periodic HIV testing for up to six months after exposure (e.g., at six weeks, 12
weeks, and six months)

Routine monitoring for toxicity with complete blood count, kidney, and liverfunction tests

Ongoing counseling and support as needed; often the emotional toll following
occupational exposure is substantial
Participant Manual: Contraception for Clients with HIV Curriculum
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Special Considerations for Pregnant Women
A pregnant health care worker who becomes occupationally exposed to HIV must be given full
information about what the injury means to her and her baby, and the known and unknown
potential risks and benefits to her and her baby associated with the use of antiretroviral drugs.
Counseling sessions with the pregnant health care worker should include discussions about:
 The potential risk for HIV transmission based on the type of exposure
 Risk relative to the stage of pregnancy (the first trimester is the period of maximal risk)
 What is known about how prophylactic drugs work in the body, their safety, and tolerability
Studies are under way to determine the safety of various ARV drugs during pregnancy. However,
at this time, efavirenz is the only drug that should be avoided in the first trimester due to concerns
that it may induce birth defects; use after the second trimester of pregnancy can be considered if
other alternatives are not available.
Postexposure care should not be withheld for exposed health care staff because they are pregnant.
Testing the Source Patient and Related Issues
When the HIV status of the source patient is not known, this person must be informed
about the accident in order to obtain consent to test for HIV. Confidentiality of the results
is an important quality of care element and must be maintained. The source patient has the
right to refuse testing.
If the person refuses or consent is not possible (e.g., the patient is unconscious),
prophylaxis should be considered if there are indications of possible infection (e.g., high
prevalence of infection among patients in the institution or suspicion of a risk factor in the
source patient). When the HIV status is unknown and a decision about initiating PEP must
be made, assume that the source patient is infected if the exposure occurs in a country with
a high prevalence of HIV.
Postexposure Care Recommendations for Facilities

Have in place or create a mechanism for reporting workplace injuries to facility
authorities, noting the type of exposure and the actions taken. If completion of accident
forms is required, complete and submit them to the appropriate authorities. Accident
forms should include information about how the incident occurred, who witnessed the
incident, and the name of the source patient if known.

Provide written guidelines for health care supervisors and staff regarding
recommended immediate care, HIV risk assessment, voluntary counseling, HIV
testing, prophylaxis, and follow-up, based on international standards for accidental
exposure to blood and other body fluids. Periodically review policies for consistency
with international standards.

Provide in-service training of all health care staff on prevention and management of
occupational exposure to blood and other body fluids.

Establish a system to manage postexposure care at all hours, with access to counseling
and available antiretroviral drugs.
Sources:
Reducing Stigma and Discrimination Related to HIV and AIDS, Participant’s Handbook. New York: EngenderHealth, 2004.
U.S. Centers for Disease Control and Prevention. Updated U.S. Public Health Service guidelines for the management of
occupational exposures to HIV and recommendations for postexposure prophylaxis. MMWR 2005;54(RR9).
U.S. Centers for Disease Control and Prevention. Updated U.S. Public Health Service guidelines for the management of
occupational exposures to HBV, HCV, and HIV and recommendations for postexposure prophylaxis. MMWR
2001;50(RR11).
Sherer R, Agins B, Teter C. Chapter 11: Postexposure prophylaxis. In Bartlett J, Cheever L, Johnson M, Paauw D, eds.
A guide to Primary Care of People with HIV/AIDS 2004 Edition. Washington, DC: U.S. Department of Health and Human
Services, Health Resources and Services Administration, HIV/AIDS Bureau, 2004.
Public Health Service Task Force. Recommendations for Use of Antiretroviral Drugs in Pregnant HIV-Infected Women for
Maternal Health and Interventions to Reduce Perinatal HIV Transmission in the United States. November 2, 2007.
Participant Manual: Contraception for Clients with HIV Curriculum
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Recognizing and Coping with Stress in Health Care Settings
Counseling and treating clients with HIV is difficult and produces many emotions. Emotional
factors can influence how a counselor performs her or his job. Providers must effectively cope
with emotional issues to perform their jobs and maintain a commitment to their workplace. In the
course of their work, a provider may experience some of the following emotions:
Confusion
•
•
•
•
Being unsure of what to do or how to act with a client
Being too involved with the life and problems of a client
Confusing one’s feelings with those of a client
Feeling a conflict between the desire to help and the fear of acquiring HIV
Fatigue
•
•
Becoming physically and emotionally tired
Needing to relax and to have a way of recovering strength
Exhaustion
•
•
Becoming chronically weary
Losing empathy for clients and the joy of work
Positive experiences –
hold on to and value them.
Negative experiences –
uncover and manage them.
Impatience and frustration
•
•
•
•
•
•
With a client who has difficulty understanding
With a client who has difficulty expressing herself or himself
With a client who disagrees with you or the institution
With a client whose attitudes or behavior bother you
With the work environment, coworkers, or management
With a health system that does not have adequate resources to help people
Anger
•
•
Frustration leading to anger
Feeling so angry that you no longer want or are able to go on (unconsciously or not)
Impotence
•
Not knowing how to help a client when her or his needs go beyond the institutional or
professional resources available
• Sharing a client’s despair about the incurability of HIV
Develop creative ways to
restore strength and
Boredom
enthusiasm
• Work becomes routine and the mystique surrounding it is gone
Burnout
•
The emotional toll of listening to clients’ problems becomes distressing, overwhelming, or
depressing
Ambivalence
•
Feelings conflict – you may sympathize but avoid expressing feelings or making a
commitment
Competition or envy
•
Differences in power or status among medical staff, community health agents, or aides
generate struggles or friction; work and clients suffer as a result
Stress and pressure are provoked by
•
•
•
Working with a disease that carries a stigma due to religious, cultural, or social norms
Overwork, the demands of a challenging job, or the negative attitudes of coworkers
Difficulty in communicating about sexuality and the social consequences of breaking taboos
Fear of contracting the HIV virus
•
Fear of contracting HIV from clients with HIV generates anxiety in general and uneasiness
around patients in particular
Positive feelings and emotions
•
A counselor may have positive experiences, such as reaching goals and earning appreciation
from the client, but if such successes are accompanied by a heavy workload and a lack of
recognition by management, their positive impact is diminished
Source: Trainer’s Guide in Sexual Health, Section 1, Exercise 5. New York: IPPF/WHR, 2002.
Participant Manual: Contraception for Clients with HIV Curriculum
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Participant Manual: Contraception for Clients with HIV Curriculum
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Adapted from: Transfer of Learning: A Guide to Strengthening the Performance of Health Care Providers, IntraHealth, 2002.
Participant Manual: Contraception for Clients with HIV Curriculum
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FACT SHEET 1. Male and Female Condoms
The male condom is a thin sheath usually made of rubber (latex) that is placed
on an erect penis before intercourse.
The female condom is a thin, soft, loose-fitting plastic (polyurethane) pouch
that lines the vagina. It has two flexible rings: an inner ring at the
closed end, used to insert the device inside the vagina and to
hold it in place, and an outer ring which remains outside the
vagina and covers the external genitalia. Because the device
is made from polyurethane, the female condom can be used
with any type of lubricant (water- or oil-based) without
compromising the integrity of the device.
Condoms are the only method of contraception that also provide protection
from sexually transmitted infections (STIs), including HIV.
Mechanisms of action
Condoms serve as a physical barrier, preventing sperm from entering the female
reproductive tract. They also serve as a barrier for infectious microorganisms, preventing
transmission of STIs/HIV from one sexual partner to another.
Characteristics of condoms (includes both male and female condoms)










Safe
Prevent both pregnancy and STIs/HIV (when used consistently and correctly)
Not as effective for pregnancy prevention as other methods in typical use
Easy to initiate and discontinue
Require motivation to use consistently and correctly
Require partner’s cooperation
Immediate return to fertility
Have virtually no side effects
May interrupt sexual activity or reduce sexual pleasure
Require proper storage and resupply
Additional characteristics of the female condom





Female-controlled
May be more comfortable to men, less decrease in sensation than with the male latex
condom
Provides additional protection to external genitalia
Can be inserted before intercourse
Stronger (polyurethane is 40 percent stronger than latex)
Possible side effects (generally not signs of a health problem)


Allergic reactions to latex (in male condoms) can occur in rare cases.
There are no known side effects with the female condom.
Participant Manual: Contraception for Clients with HIV Curriculum
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Who can use condoms
Women and men of any reproductive age who:
 want to use this method for STI/HIV prevention, contraception, or both.
 have no severe allergy to latex (male condom only). However, if the client is at risk of
STIs/HIV, he or she may want to continue using condoms despite the allergy.
Provide follow-up and counseling for



Correct and consistent use
Common problems in use and how to overcome those
Use of emergency contraception as a backup method for pregnancy prevention in case
condom was not used or breaks or slips
Assess the client’s risk for STIs/HIV and discuss the need for condom use for disease
prevention.
Dispelling myths regarding condoms
Condoms do not:
 make men weak or impotent
 get lost in a woman’s vagina (if they slip)
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FACT SHEET 2. Combined Oral Contraceptives (COCs)
Combined oral contraceptives (COCs) are pills that are taken once
per day to prevent pregnancy. They contain the hormones
estrogen and progestin.
Primary mechanisms of action


Prevent ovulation (release of eggs from the ovaries)
Thicken cervical mucus (make it difficult for sperm to
penetrate)
Characteristics of COCs











Safe and very effective if used consistently and correctly
Reversible, rapid return to fertility
Do not interfere with intercourse
Easy to discontinue use
Have beneficial non-contraceptive effects (regular menstrual cycles; lighter menses;
fewer menstrual cramps; protection from ectopic pregnancy, ovarian and endometrial
cancer, and symptomatic pelvic inflammatory disease; may help protect against
ovarian cysts and anemia; reduce symptoms of endometriosis)
Require daily use
Incorrect use is common (easy to miss taking a pill)
Require resupply
No protection against sexually transmitted infections including HIV
Have common side effects
Serious complications very rare
Possible side effects of COCs (generally not signs of a health problem)







Headaches, dizziness
Nausea
Breakthrough bleeding or spotting
Breast tenderness
Mood changes
Weight change
Amenorrhea
Who can use COCs
Women of any parity or reproductive age who:
 want to use this method of contraception
 have no health conditions that preclude the use of COCs
Participant Manual: Contraception for Clients with HIV Curriculum
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Who should not use COCs (for a complete list, see WHO eligibility criteria)
Women who have the following conditions (contraindications):
 breastfeeding, during the first six weeks postpartum (also not a good method for
women who want to continue breastfeeding up to six months)
 first three weeks postpartum if not breastfeeding
 age 35 or older, who smoke heavily (15 cigarettes/day or more)
 current breast cancer
 severe cirrhosis; malignant liver tumors; or benign liver tumors, with the exception of
focal nodular hyperplasia (which is a tumor that consists of scar tissue and normal
liver cells)
 cardiovascular conditions (i.e., high blood pressure; diabetes with vascular
complications; history of or current deep venous thrombosis, stroke, or ischemic heart
disease)
 migraine with aura or any migraine in women older than age 35
 taking drugs that affect liver enzymes: rifampicin or rifabutin (for tuberculosis),
anticonvulsants (for epilepsy), or ritonavir (as part of an antiretroviral regimen).
COC use by women with HIV and AIDS



Women with HIV and AIDS can use COCs without restrictions.
Women with AIDS who take antiretroviral drugs (ARVs), other than ritonavir, can
generally use COCs. (There is some evidence that ritonavir reduces the blood levels of
contraceptive hormones to a much greater extent than other ARV drugs.)
Women with HIV who choose to use COCs should be counseled about dual method
use and consider using condoms in addition to COCs. In addition to preventing the
spread of HIV, condoms may be especially beneficial to women on ARVs because
condoms provide additional protection from pregnancy in the event that COC
effectiveness is reduced by ARVs.
Provide follow-up and counseling for




Any client concerns or questions
Common side effects
Correct COC use (ability to take pills on schedule, what to do when pills
are missed)
Any signs of complications (thrombosis or thromboembolism); counsel the woman to
come back immediately if any of the following symptoms develop:
 severe chest pain or shortness of breath
 severe headache with vision problems
 sharp pain in leg or abdomen
Dispelling myths regarding COCs
Contraceptive pills do not:
 cause birth defects
 cause infertility
 require a “rest” period
 decrease sex drive
 build up in a woman’s body
Participant Manual: Contraception for Clients with HIV Curriculum
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FACT SHEET 3. Progestin-Only Injectables
Progestin-only injectable contraceptives (e.g., Depo-Provera, Noristerat)
contain no estrogen. To prevent pregnancy, a shot is given every two or
three months, depending on the type of injectable.
Primary mechanisms of action


Prevent ovulation (release of eggs from the ovaries)
Thicken cervical mucus (make it difficult for sperm to penetrate)
Characteristics of progestin-only injectables








Highly effective
Easy to use
Reversible with some delay in return to fertility (pregnancy occurs
on average four months later than other modern methods)
Do not interfere with intercourse, private
Have no affect on quality or quantity of breast milk
Have beneficial non-contraceptive effects (protection from endometrial cancer,
uterine fibroids, ectopic pregnancy, and symptomatic pelvic inflammatory disease;
may reduce sickle crises in women with sickle cell anemia)
Have common side effects
Provide no protection from sexually transmitted infections including HIV
Possible side effects (generally not signs of a health problem)





Irregular menstrual bleeding or spotting or heavy bleeding (more common during the
first few months of use)
Amenorrhea (common, especially after the first year of use)
Weight gain
Headaches and dizziness (less common than with combined oral contraceptives)
Changes in mood and sex drive
Who can use progestin-only injectables
Women of any parity or reproductive age who:
 want to use this method of contraception
 have no contraindications
Participant Manual: Contraception for Clients with HIV Curriculum
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Who should not use progestin-only injectables (for a complete list, see WHO
eligibility criteria)
Women who have the following conditions (contraindications):
 breastfeeding while less than six weeks postpartum
 multiple risk factors for cardiovascular disease
 blood pressure more than 160/100 mmHg
 acute deep venous thrombosis (unless on established anticoagulant therapy)
 current or history of ischemic heart disease or stroke
 unexplained vaginal bleeding (before evaluation)
 history of or current breast cancer
 diabetes with vascular complications
 severe cirrhosis; malignant liver tumors; or benign liver tumors, with the exception of
focal nodular hyperplasia (which is a tumor that consists of scar tissue and normal
liver cells)
Use of progestin-only injectables by women with HIV and AIDS
DPMA:
 Can be used without restrictions by women with HIV who may or may not have AIDS
including those taking antiretroviral drugs (ARVs).
 Women with HIV who choose to use DMPA should be counseled about dual method
use and consider using condoms in addition to DMPA to prevent transmission of HIV.
NET-EN:
 Can generally be used, however, women on ARV therapy should be encouraged to
receive the next injection on time (by the end of the two-month period).
 Women with HIV who choose to use NET-EN should be counseled about dual method
use and consider using condoms in addition to injectable contraceptives. In addition to
preventing the spread of HIV, condoms may be especially beneficial to women on
ARVs because condoms provide additional protection from pregnancy in the event that
the effectiveness of the injectable is reduced by ARVs.
Provide follow-up and counseling for



Any client concerns or questions
Common side effects, especially irregular bleeding or spotting, or amenorrhea
Importance of timely injection
Dispelling myths regarding progestin-only injectables
Progestin-only injectables do not:
 cause birth defects
 cause permanent infertility
Participant Manual: Contraception for Clients with HIV Curriculum
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FACT SHEET 4. Progestin-Only Implants
Progestin-only implants consist of hormone-filled
capsules or rods that are inserted under the skin in a
woman’s upper arm. The Norplant implant system is a
set of six thin, flexible capsules made of silicone that is
effective for five years. Jadelle was designed to deliver
the same daily dose of levonorgestrel that Norplant
delivers but is two rods instead of six and is effective for five
years. Sinoplant is nearly identical to Jadelle
but contains more levonorgestrel. Implanon –
a single-rod system – continually releases a
low, steady dose of the progestin etonogestrel
for a period of up to three years.
Primary mechanisms of action


Thicken cervical mucus (make it difficult for sperm to penetrate)
Partially prevent ovulation (in about half of menstrual cycles)
Characteristics of progestin-only implants











Highly effective
Easy to use
Long-acting pregnancy protection but easily reversible
Do not interfere with intercourse, private
Have no affect on quality or quantity of breast milk
Have beneficial non-contraceptive effects (help prevent ectopic pregnancy and iron
deficiency anemia)
Substantially reduce the risk of ectopic pregnancy
Have common side effects
Insertion involves minor surgical procedure and some discomfort for a day or two
Provider needed to initiate and discontinue use
Provide no protection from sexually transmitted infections including HIV
Possible side effects (generally not signs of a health problem)





Light spotting or bleeding between monthly periods
Prolonged bleeding (less common)
Amenorrhea
Weight change
Headaches, nausea, and breast tenderness (less common than with combined oral
contraceptives)
Who can use progestin-only implants
Women of any parity or reproductive age who:
 want to use this method of contraception
 have no contraindications
Participant Manual: Contraception for Clients with HIV Curriculum
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Who should not initiate progestin-only implants (for a complete list, see WHO
eligibility criteria)
Women who have the following conditions (contraindications):
 breastfeeding while less than six weeks postpartum
 acute deep venous thrombosis (unless on established anticoagulant therapy)
 unexplained vaginal bleeding (before evaluation)
 history of or current breast cancer
 severe cirrhosis; malignant liver tumors; or benign liver tumors, with the exception of
focal nodular hyperplasia (which is a tumor that consists of scar tissue and normal
liver cells)
Use of progestin-only implants by women with HIV and AIDS


Women with HIV and AIDS who do not take antiretroviral drugs (ARVs) can use
progestin-only implants without restrictions.
Women with AIDS on antiretroviral drugs (ARVs) generally can use progestin-only
implants but should be counseled about dual method use and consider using condoms
in addition to implants. Besides preventing the spread of HIV, condoms may be
especially beneficial to women on ARVs because condoms provide additional
protection from pregnancy in the event that the effectiveness of the implant is reduced
by ARVs.
Provide follow-up and counseling for



Any client concerns or questions
Common side effects, especially irregular bleeding or spotting or amenorrhea
Any signs of complications; counsel the woman to come back immediately if any of
the following symptoms develop:
 unusually heavy or prolonged bleeding
 severe pain in the lower abdomen (ectopic pregnancy)
 infection at the insertion site
 very bad headaches that start or become worse after initiation
 unusually yellow skin or eyes
Explain to client that implants can be removed any time for any reason.
Dispelling myths regarding progestin-only implants
Progestin-only implants do not:
 break and move around within a woman’s body
 cause birth defects
 cause cancer
Participant Manual: Contraception for Clients with HIV Curriculum
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FACT SHEET 5. Emergency Contraceptive Pills (ECPs)
Emergency contraceptive pills (ECPs) refer to the special regimen of oral contraceptives used to
prevent pregnancy after unprotected intercourse. Two common regimens of ECPs are:
 Progestin-only regimen
 Combined estrogen-progestin (Yuzpe) regimen
ECPs prevent between 75 percent and 95 percent of expected pregnancies with the
progestin-only regimen being more effective than the Yuzpe regimen. ECPs should be
started as soon as possible but generally not later than 120 hours after unprotected
intercourse. The sooner ECPs are taken, the more effective they are (e.g., the progestinonly regimen taken within 24 hours after unprotected intercourse prevents 95 percent of
expected pregnancies).
Mechanism of action of ECPs
 Prevent or delay ovulation (main mechanism)
 May also have effects after ovulation, possibly preventing fertilization
Once implantation has occurred, ECPs are no longer effective. They do not interrupt an
established pregnancy and, if accidentally taken, do not pose any danger to the mother or
fetus. Thus, ECPs are not abortifacients.
When to use ECPs
Emergency contraception may be considered in a number of situations when unprotected
intercourse occurs. These situations include occasions when:
 No regular contraceptive method was used.
 A method was used, but failed, e.g., the condom broke or slipped during intercourse.
 A method was used incorrectly, e.g., forgetting to take contraceptive pills on time or
miscalculating the safe time during the menstrual cycle when using fertility awarenessbased methods.
 A woman was coerced into having sex or was raped.
How to take the progestin-only regimen



Take 2 pills containing 0.75 mg of levonorgestrel within 120 hours after
unprotected intercourse.
OR
Take one pill containing 0.75 mg of levonorgestrel within 120 hours after
unprotected intercourse.
Take another pill containing 0.75 mg of levonorgestrel 12 hours after the
first pill.
Where pre-packaged ECPs containing 0.75 mg of levonorgestrel are not
available, the required amount of hormone for each dose could be obtained, for
example, by taking 20 progestin-only pills (POPs) containing 0.0375 mg of
levonorgestrel each (40 total pills).
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How to take the combination estrogen-progestin regimen (Yuzpe)
Regular combined oral contraceptive pills (COCs) can be used for this purpose.
The number of COC pills taken for each dose will vary depending on the amount
of hormones in each pill; however, each dose should contain at least 0.1 mg of
ethinyl estradiol and 0.5 mg of levonorgestrel.
When “low-dose” COCs are used (containing 0.03 mg of ethinyl estradiol each):
 Take 4 pills within 120 hours after unprotected intercourse.
 Take another 4 pills 12 hours after the first dose.
When “high-dose” COCs are used (containing 0.05 mg of ethinyl estradiol each):
 Take 2 pills within 120 hours after unprotected intercourse.
 Take another 2 pills 12 hours after the first dose.
Characteristics of ECPs
 Safe, effective, and easy to use
 Can be used at any time during the menstrual cycle
 Can be provided without a prescription
 Do not prevent sexually transmitted infections (STIs) including HIV
 Have short-term side effects
Possible side effects of ECPs (generally not signs of a health problem)
 Nausea
 Vomiting
 First menstruation after use of ECPs is likely to come a few days earlier or later than
usual
Nausea and vomiting both are more common for the Yuzpe regimen than for the progestinonly regimen.
Who can use ECPs
 Any woman who does not want to become pregnant, including women with HIV and
AIDS and those who take antiretroviral drugs (ARVs)
Even if the blood levels of hormones are reduced by ARVs, ECPs still should provide some
level of protection from unwanted pregnancy.
There are no known contraindications for ECPs.
Provide follow-up and counseling for
 Any symptom or concern of the client
 Common side effects
 Ongoing contraception if client wants to avoid pregnancy
 Prevention of STIs and HIV
Dispelling myths regarding emergency contraceptive pills
 ECPs do not cause abortion and will not harm an established pregnancy.
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FACT SHEET 6. Intrauterine Device – TCu-380A
An intrauterine device (IUD) is a small device inserted into a woman’s uterine cavity to
prevent pregnancy. The IUD containing copper (TCu-380A) is the most commonly used
and is effective for up to 12 years.
Primary mechanisms of action
Prevents fertilization by:
 impairing viability of sperm
 interfering with sperm movement
Characteristics of IUDs
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Highly effective
No constant supplies needed
Easy to use
Does not interfere with intercourse
Rapid return to fertility
Have beneficial non-contraceptive effects (protection from endometrial cancer and
ectopic pregnancy)
Provider needed to initiate and discontinue use
May cause minor pain or discomfort during insertion and removal procedures
Has common side effects
Complications are rare (i.e., pelvic inflammatory disease and uterine perforation)
Small risk of expulsion (woman needs to check for IUD strings after menses)
No protection against sexually transmitted infections including HIV
Possible side effects (generally not signs of a health problem)
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Pain or cramping during menses
Prolonged and heavy menstrual bleeding
Bleeding or spotting between monthly periods
Who can have an IUD inserted
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Women of any parity or reproductive age, including young and nulliparous women.
Women who have no health conditions that preclude the use of an IUD.
Who should not have an IUD inserted (for a complete list, see WHO eligibility criteria)
Women who have the following conditions (contraindications):
 pregnancy
 septic infection following childbirth or abortion (if insertion is immediately
postpartum or postabortion)
 unexplained vaginal bleeding (before evaluation)
 cervical, endometrial, or ovarian cancer
 current pelvic inflammatory disease
 current purulent cervicitis (gonorrhoea or chlamydia)
 malignant gestational trophoblastic disease
 known pelvic tuberculosis
 uterine fibroid or other anatomical abnormalities resulting in distortion of the uterine
cavity, which is incompatible with IUD insertion
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IUD use by women with HIV and AIDS
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An IUD can be provided to a woman with HIV if she has no symptoms of AIDS.
An IUD generally should not be initiated in a woman with AIDS who is not taking
antiretroviral drugs (ARVs).
A woman who develops AIDS while using an IUD can continue to use the device.
A woman with AIDS who is doing clinically well on ARV therapy can both initiate
and continue IUD use, but follow-up may be required.
Women with HIV who choose to use an IUD should be counseled about dual method
use and consider using condoms in addition to the IUD.
Provide follow-up and counseling for
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Any client concerns or questions
Common side effects
Any signs of complications; counsel the woman to come back immediately if any of
the following symptoms develop:
 bleeding or severe abdominal cramping during the first three to five days after
insertion (perforation)
 irregular bleeding or pain in every cycle (possible dislocation, partial expulsion, or
perforation)
 fever and chills, unusual vaginal discharge, or low abdominal pain (possible
infection)
 missing strings (possible expulsion)
 missing or delayed menstrual period (possible pregnancy)
Dispelling myths regarding IUDs
IUDs do not:
 migrate from the woman’s uterus to other parts of her body
 prevent a woman from having children after it is removed
 require a “rest” period (a new IUD can be inserted the same day the existing IUD is
removed)
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FACT SHEET 7. Female and Male Sterilization
Female sterilization is a surgical procedure where the
fallopian tubes, which carry eggs from the ovaries to the
uterus, are blocked (tied and cut, cauterized, or
interrupted by a ring or clip). Sterilization ends fertility
permanently (less than 2 percent failure over 10 years).
A vasectomy is a minor surgical procedure that permanently ends
fertility in men by making a small opening in the man’s scrotum and
closing off both tubes that carry sperm from his testicles.
Primary mechanisms of action

Female sterilization: blocks the fallopian tubes to prevent sperm
from uniting with an egg, thereby preventing fertilization.
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Male sterilization: interrupts the vas deferens, preventing the sperm from entering the
semen, so that semen is ejaculated without sperm.
Characteristics of sterilization
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Highly effective
Permanent
Has no systemic side effects
Does not interfere with intercourse
Easy to use
Female sterilization has beneficial non-contraceptive effects (partial protection from
ovarian cancer and pelvic inflammatory disease)
Chance of regret
Surgical procedure (associated discomfort)
No protection from sexually transmitted infections including HIV
Female sterilization: high chance of ectopic pregnancy in rare case where the operation
fails and the woman becomes pregnant
Male sterilization: effectiveness is delayed by approximately three months; must use
another method for the three months immediately following the procedure
Possible side effects of sterilization (generally not signs of a health problem)
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Some pain and discomfort during and immediately after the procedure
Rare complications associated with the procedure itself
Who can use sterilization
Women and men of any reproductive age or parity who:
 are certain they do not want or must not have more children and desire permanent
protection from pregnancy
 have no conditions that may require sterilization to be delayed
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Who should delay sterilization (for a complete list, see WHO eligibility criteria)
Women who have the following conditions:
 pregnancy
 between seven and 42 days postpartum
 postpartum or postabortal sepsis or severe hemorrhage or genital trauma
 severe pre-eclampsia/eclampsia
 prolonged rupture of membranes (24 hours or more)
 current unexplained vaginal bleeding, suspicious for a serious condition but not yet
evaluated
 acute deep venous thrombosis (unless on established anticoagulant therapy)
 current ischemic heart disease
 gynecological cancer
 current gonorrhea, chlamydia, or pelvic inflammatory disease
 current gall-bladder disease or acute viral hepatitis
 acute respiratory disease
 abdominal skin infection
 systemic infection or gastroenteritis
Men who have the following conditions:
 local infection (scrotal skin infection, active sexually transmitted infection, balanitis,
epididymitis, or orchitis)
 systemic infection or gastroenteritis
 intrascrotal mass
Sterilization use by clients with HIV and AIDS
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Clients with HIV and AIDS and those on antiretroviral therapy can use sterilization
unless they have acute AIDS-related illness that may require that the procedure be
delayed.
Provide follow-up and counseling for
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Any client concerns or questions.
Permanent nature of the procedure. Thorough counseling is very important as clients
most likely to regret sterilization can be identified through counseling.
Time-to-effectiveness with male sterilization. Because it takes approximately three
months for sperm to clear the vas, emphasize the need to use another contraceptive
method (e.g., condom) for three months after vasectomy.
Signs of infection (follow-up one week after the procedure to check the surgical site or
any time soon after the procedure if signs of infection are present).
Dispelling myths regarding sterilization
Sterilization is not:
 a castration
 associated with loss of masculinity
 associated with a decreased sex drive
 easily reversible; although reversal is possible in some cases, it is very expensive,
requires a specially trained provider and, even then, the success rates are low
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FACT SHEET 8. HIV and Breastfeeding
Risk of mother-to-child transmission
• Without treatment, about a third of HIV-positive mothers
pass the virus to their newborns during pregnancy,
delivery, and breastfeeding.
• In the absence of any interventions, approximately
16 percent of infants born to HIV-positive women will
be infected through breastfeeding.
• HIV transmission may continue for as long as a child is
breastfed.
• The risk of HIV transmission through breastfeeding is
nearly twice as high among women who have been
recently infected with HIV.
Women with HIV face the dilemma of trying to prevent HIV transmission to their infants
during feeding while reducing the risk of malnutrition and other illnesses if they do not
breastfeed.
Health risks for non-breastfed infants
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Not breastfeeding, compared with any breastfeeding, has been shown to expose
children to an increased risk of malnutrition and life-threatening infectious diseases
other than HIV, especially in the first year of life.
Exclusive breastfeeding appears to offer greater protection against disease than any
breastfeeding.
In developing countries, as many as 54 percent of all deaths among children under the
age of five are associated with malnutrition.
In developing countries, not breastfeeding during the first two months of life is
associated with a six-fold increase in mortality due to infectious diseases. This increased
risk drops to two-and-a-half-fold at six months, and continues to decrease with time.
Types of infant feeding
Exclusive breastfeeding
Means the infant receives only breast milk from the mother or a wet nurse, or expressed
breast milk and no other liquids or solids (with the exception of drops or syrups consisting
of vitamins, mineral supplements, or medicines). A child may be exclusively breastfed with
expressed human milk from the mother, a breast-milk donor, or a milk bank.
Replacement feeding
Means the process of feeding a child who is not receiving any breast milk with a diet that
provides all the nutrients the child needs. During the first six months, this should be with a
suitable breast-milk substitute – commercial formula or home-prepared formula with
micronutrient supplements. After six months, the diet should consist of a suitable breastmilk substitute and complementary foods made from appropriately prepared and nutrientenriched family foods, given two to three times per day. If suitable breast-milk substitutes
are not available, appropriately prepared family foods should be further enriched and given
five times a day.
Partial breastfeeding or mixed feeding
Means giving a baby some breastfeeds and some artificial feeds, either milk, cereal, or
other food.
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Breastfeeding options for women with HIV
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The most appropriate infant-feeding option for an HIV-positive mother should
continue to depend on her individual circumstances, including her health status and the
local situation, but should take greater consideration of the health services available
and the counseling and support she is likely to receive.
Exclusive breastfeeding is recommended for HIV-positive women for the first six
months of the infant’s life unless replacement feeding is acceptable, feasible,
affordable, sustainable, and safe for them and their infants before that time.
When replacement feeding is acceptable, feasible, affordable, sustainable, and safe,
avoidance of all breastfeeding by HIV-positive women is recommended.
At six months, if replacement feeding is still not acceptable, feasible, affordable,
sustainable, and safe, continuation of breastfeeding with additional complementary
foods is recommended, and the mother and baby should continue to be regularly
assessed. All breastfeeding should stop once a nutritionally adequate and safe diet
without breast milk can be provided.
Mixed feeding with both breast milk and other feeds has been associated with a higher
risk of HIV infection for the infant than exclusive breastfeeding and should be avoided
because it increases the risks of both HIV infection and the risks of diarrhea and other
infectious diseases.
In cases where an infant or young child is known to be HIV-positive, the mother
should be strongly encouraged to continue breastfeeding because it has been shown to
improve child survival.
To make the best choice, HIV-positive women should
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Receive counseling that includes information about both the risks and benefits of
various infant-feeding options.
Receive guidance in selecting the most suitable option for their situation.
Have access to follow-up care and support, including family planning and nutritional
support, particularly at key points when feeding decisions may be reconsidered, such
as the time of early infant diagnosis and at six months of age.
Source:
UNICEF, UNAIDS, WHO, UNFPA. HIV and Infant Feeding: Guidelines for decision-makers.
Geneva: WHO, 2003.
World Health Organization (WHO). Consensus Statement – WHO HIV and Infant Feeding Technical
Consultation. Held on behalf of the Inter-agency Task Team (IATT) on Prevention of HIV Infections in
Pregnant Women, Mothers and their Infants, October 25-27, 2006. Geneva: WHO, 2006.
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